Complaint Against a Health Care Facility/Provider

To file a complaint against a health care facility or provider, please fill out this form and click “submit” at the bottom of the page. Provide as much detail as possible. Your complaint will be routed to the appropriate Licensing and Certification (L&C) District Office for investigation. If you prefer to file your complaint in person or by mail, please use the L&C District Office information directly below.

Facility Information

Facility/Provider Name:

Street Address:

City/State/ZIP Code:

L&C District Office Information

Complainant Information (Optional) If you prefer to remain anonymous, please proceed to the Patient/Resident Information section. Otherwise, provide your contact information directly below.

Do you prefer to remain anonymous? ^* Yes No

Name:

Email:

Phone:

Mailing Address:

Max Length: 100 Characters

Complaint Details

Patient/Resident Information

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

Complaint

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”.

Page Last Updated : March 8, 2018

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Complaint Against a Health Care Facility/Provider

Facility Information

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Patient/Resident Information

Complaint