Confidential Patient Complaint Form Page 2
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2FOR OFFICE USE ONLY
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Delay due to state
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Administration
State Agency/Law
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Office
Business Office
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Finance
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Double Billed
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State
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Patient Registration
Date Received by Practice Manager: ________________ Signature:_____________________________________
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Followed up by:
Letter
Phone
In-Person Date of Follow Up/Final Letter mailed out:__________________
CONCERN CATEGORIES
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Personal Interaction
Repeated Complaint
(one incident)
Attitude
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Unprofessional Conduct
Individual with multiple complaints
Was issue resolved?
YES or NO
Describe action taken to resolve issue: __________________________________________________________
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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If not, state reason(s) why: ____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Parent category: Legal