PACE Concern Submission Form

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Anyone can report a concern about the PACE program or a PACE participant. You can report your PACE concern by completing the form below. Your concern will be submitted to the PACE administrator. Please enter all required information in the blank fields below. When you are done, select ‘submit’. The PACE administrator will get your submission and contact you to address your concern.

Requester's Name

First

Last

Participant's Name

First:

Last:

Today's Date

Date the Concern Happened:

(if you do not know the exact date, please describe the timeframe or closest date in the next field)

Description Timeframe

Describe Your Concern:

Preferred Contact Method:

Phone Number:

Email Address:

Email Address

Address

City/Town

State/Province

ZIP/Postal Code

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The PACE administrator will need all the information requested in this form. If you cannot use this form, you can submit your concern to the PACE administrator by:

Email: dhspacetosaainfo@nd.gov
Phone: (701) 328-2838
Toll-Free: (800) 755-2604
TTY: 711
Mail:
North Dakota Health and Human Services
Medical Services Division
Attn: PACE administrator
600 E. Boulevard Ave., Dept. 325
Bismarck, ND 58505-0250
Fax: (701) 328-1544