Patient Complaint / Grievance Form

Use this form to document a patient complaint or grievance. Forward concerns requiring formal review to Administration

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Patient Name

First

Last

Medical Record Number

Patient Date of Birth

Email Address

Phone Number

Person Completing Form / Relationship

Date(s) of Service

Department / Location

Staff or Provider(s) Involved

Date(s) Form Description

Nature of Concern

Quality of Care
Patient Safety
Staff Conduct
Communication
Delay in Care
Billing
Privacy / HIPAA
Patient Rights
Environment
Other

Description of Concern

Desired Resolution

Signature

Please type your name.

Date

Preferred Contact Method

Phone
Mail
Email

All information provided in this grievance form will be handled with strict confidentiality. Details of this complaint will be shared only with individuals who need to know in order to investigate and resolve the matter. We will make every reasonable effort to protect the privacy of all parties involved, though information may be disclosed as required by law or to ensure a fair process.

**Upon completion, please submit to the Chief Executive Officer