Complete this form if you have concerns about the health care or treatment that you or a family member received or did not receive. Answer all questions. Give complete details. Use as much space as necessary. We will investigate your concerns based on the information that you provide. You may file an anonymous complaint. You may use this form as a guide when making a complaint by telephone.
Our complaint hotline number is (202) 442-5833.
I. Name of patient/resident/client involved in the incident:
Last Name:
First Name:
Sex: Male Female
Age:
Room # (If Known)
II. Health care facility:
Name:
Provider # (If Known)
Address - Street & Number:
City:
State:
Zip Code:
Check the type of facility or program:
Nursing Home Hospital Home Health Agency Hospice Dialysis Center Ambulatory Surgical Center Birthing Center Medical Laboratory Group Homes for the Mentally Retarded Other. Please specify:
III. Briefly describe the incident or your concerns (use additional space if necessary):
Include dates and times, persons involved, and description of what happened. Include attachments, if appropriate. Note: If this is an anonymous report, be complete since we will not be able to contact you to obtain missing information, which may impede the investigation.
IV. Witnesses to the incident:
Name:
Contact information, if known (include telephone number):
V. Person or entity filing complaint or reporting incident (optional):
Note: If you would like a report that may result from our investigation, please complete this section.
09 Current Staff Member 10 Family Member 11 Coroner (Medical Examiner) 12 CMS 13 Transferring Entity 14 Quality Improvement Organization 15 State Surveyor 99 Other
Name:
Relationship:
Address:
City:
State:
Zip Code:
Telephone:
May we reveal your identity during the investigation of your complaint? Yes No
VI. Have you reported this incident or concern to the person in charge of the facility, residence or program?
No Yes. Provide name and position of person(s). Name Position
