Health Facility Concerns

Report a Health Facility Unit Concern

This form is for the public to report a concern to the Health Facilities Unit.

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?

Health Facilities Unit
Department of Health and Human Services
1720 Burlington Drive, Suite A
Bismarck ND 58504-7736
Phone: (701) 328-2352, 711 (TTY)
Fax: (701) 328-1890
Email: hfconcerns@nd.gov

Last Name

First Name

Address

City

State

ZIP

Email Address

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.

Download PDF Form to Mail or Fax

Health Facilities Unit
Department of Health and Human Services
1720 Burlington Drive, Suite A
Bismarck ND 58504-7736
Fax: (701) 328-1890

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.