Patient Complaint Form

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Compliance Use Only:
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Patient Complaint Form
Must be filled out completely by director/manager upon notice of complaint.
Facility/Department: _____________________________________ Address: ____________________________
TODAY’S DATE
DIRECTOR / MANAGER NAME
PATIENT NAME
MRN
DATE INCIDENT OCCURRED
TIME OF INCIDENT
HEALTH INSURANCE CLAIM NUMBER
EMPLOYEE(S) INVOLVED IN COMPLAINT:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
EMPLOYEE(S) WORKING AT TIME OF COMPLAINT:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PERSON NOTIFIED OF COMPLAINT:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DESCRIPTION OF COMPLAINT:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CORRECTIVE ACTION:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FOLLOW UP:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________________________
______________________________
Patient Signature
Date
_______________________________________________________
______________________________
Director/Manager Signature
Date
FM.OF.008
UPDATED: 10-01-2013

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