Form 504 - Recipient Rights Complaint Form Page 2
Download a blank fillable Form 504 - Recipient Rights Complaint Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 504 - Recipient Rights Complaint Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Michigan Department of Licensing and Regulatory Affairs
Bureau of Health Care Services – Health Facilities Division
Substance Abuse Program
P.O. Box 30664
Lansing, MI 48909
(517) 241-1970
INSTRUCTIONS FOR THE RECIPIENT/CLIENT
RECIPIENT RIGHTS COMPLAINT FORM
HOW TO FILE A COMPLAINT
A.
You should fill out the attached form if you believe one of your rights has been violated.
B.
If you need help to write out your complaint, please see your rights advisor.
C.
If you are not sure what right was violated, ask your rights advisor for a list of your rights.
D.
After you fill out items 1 through 7 on Page 1, sign the authorization to release information form.
E.
Give the form to your rights advisor.
WHAT WILL HAPPEN
After you give the completed form to your rights advisor, he or she may ask you for additional information. The rights
advisor will then investigate your complaint and try to develop a fair solution.
Within 30 working days of the date your rights advisor receives this form, he or she will give you a written Recipient
Rights Investigation Report. That report will have a summary of what the rights advisor found while investigating
your complaint. It will have a proposed solution (action plan) if your complaint was found to require action.
YOUR RIGHT TO APPEAL
When you receive the Recipient Rights Investigation Report, you will have 15 working days to decide to accept the
findings and/or action plan proposed by the program, or to file an appeal. If you do not appeal within 15 working days,
this indicates/means you have accepted the investigation report.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize the
Program to release information contained in my program records to my coordinating agency rights consultant or
designee and to the substance abuse rights coordinator or designee.
I authorize release of information that is
necessary for the complete investigation of my recipient rights complaint and any future appeals. The release includes
authorization to interview witnesses concerning my complaint when such interviews are necessary for a complete
investigation of my complaint.
This authorization is subject to revocation at any time except in those circumstances in which the program has taken
certain actions on the understanding that the consent will continue unrevoked until the purpose for which the consent
was given shall have been accomplished.
Without expressed revocation, this authorization expires when the investigation of my complaint or subsequent appeals
has been completed.
Signature of Recipient
Date Signed
Signature of Witness
Date Witnessed
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex,
religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing,
etc., under the Americans With Disabilities Act, you may make your needs known to this agency.
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal