Complaint Against a Health Care Facility/Provider

Facility/Provider Name:

Street Address:

City/State/ZIP Code:

Do you prefer to remain anonymous? ^* Yes No

Name:

Email:

Phone:

Mailing Address:

Max Length: 100 Characters

Does your complaint involve a specific patient or resident? ^* Yes No

Date of Alleged Event:^*

Time of Alleged Event:

Describe the Event:^*

Max Length: 5000 Characters

Add an Attachment:

Allowed file formats include .DOC, .DOCX, .RTF, .TXT, .PDF, .PPT, .JPEG and .PNG. Maximum file size allowed is 20 MB.

To keep a record of this complaint, please click on the “print” button prior to clicking “submit”.

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