Health Facility Program Complaint Intake Form

Last Name

First Name

Address

Address

City

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

ZIP

Email Address ( Please provide an email address to receive a copy of your submission. )

Telephone Number (include area code)

Name of Resident/Patient

Relationship to Resident/Patient

Name of Facility

Location of Facility

Type of Health Care Facility

- None -Ambulatory Surgical CentersBasic CareRural Health ClinicsDialysisHome HealthHospiceHospital/Critical Access HospitalICE/IIDLaboratoryLong Term Care/SkilledOther - Please Specify

Other Type

Describe Complaint or Concern (give as much detail as possible including names, dates, and times)

Describe Action Taken Regarding this Complaint or Concern (if any)

Submit

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