Health Facility Concerns

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Report a Health Facility Unit Concern

Before You File:

Have you discussed your concern with the facility’s Chief Administrator and the Director of Nursing?
Have you discussed your concern with the primary provider and/or the facility’s Medical Director?

If you wish to file, contact us at:

Health Response and Licensure
Health Facilities Unit
1720 Burlington Drive, Suite A
Bismarck ND 58504-7736
Phone: (701) 328-2352
Fax: (701) 328-1890
Email: hfconcerns@nd.gov

Last Name

First Name

Address

City

State

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

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)

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Medium

Download PDF Form

Download PDF Form to Mail

Download Form

Submit by Email

Email your concern.

*Please Note: This email box is not monitored 24x7. If you have a concern that needs to be immediately addressed, please contact the Facility and speak with the Facility Staff.*

Submit by Email

Medium

*Please Note: This email box is not monitored 24x7. If you have a concern that needs to be immediately addressed, please contact the Facility and speak with the Facility Staff.*