It is important that you fill out the complaint form as complete as possible, including Facility name and address. If you want to print a copy of this form after you've completed it, use the Print button at the bottom of this page.
Your name will be kept confidential and will not be released unless ordered by the court. You are not required to give your name or contact information. However, if you do not provide it, a licensing consultant will not be able to contact you if additional information is needed. Your complaint may not be assigned or may be unconfirmed due to an inability to reach you for follow-up.
I wish to file a complaint against the facility/agency/provider named below. I am submitting this information so that it may be determined if a licensing action against this facility/agency/provider should be considered.