Complaint Form - Illinois Department Of Public Health printable pdf download

State of Illinois

Illinois Department of Public Health

COMPLAINT FORM

Illinois Department of Public Health

Office of Health Care Regulation

Central Complaint Registry

525 W. Jefferson St., Ground Floor

Springfield, IL 62761-0001

Fax Number - 217-524-8885

Central Complaint Registry Hotline - 800-252-4343

Monday-Friday 8:30 a.m. to 4:30 p.m.

TTY for the Hearing Impaired Only- 800-547-0466

Directions: Download this form and complete the following information and mail or fax it to the Illinois Department

of Public Health’s Central Complaint Registry. Your comments will assist the surveyor who will investigate the

complaint.

Complaints submitted to this site are limited to hospitals, home health agencies, hospices, end-stage renal

dialysis units, ambulatory surgical treatment centers, rural health clinics, critical access hospitals, clinical

laboratories (CLIA), outpatient physical therapy, portable X-ray services, community mental health centers,

accredited mental health centers (only Medicare Certified), comprehensive outpatient rehabilitation facilities,

health maintenance organizations (HMOs), nursing homes, skilled nursing homes, licensed facilities for develop-

mentally disabled and assisted living facilities. The Department’s Central Complaint Registry is limited to the

mandates provided in the licensing acts, regulations, and federal Medicare Conditions of Participation or

coverage for the programs the Department manages.

Date of Occurrence _____________________

Facility __________________________________________________________________________________

Address __________________________ City _____________________ State ____ ZIP Code ____________

To receive a letter explaining the outcomes of the investigation, please include mailing address:

Complainant Name (if patient, provide date of birth and sex) ________________________________________

(May remain anonymous)

Address __________________________ City _____________________ State ____ ZIP Code ____________

Daytime Telephone (

) __________________ cell (

) __________________

Name of Patient/Resident (if different than complainant)____________________________________________

Date of Birth ________________ Sex ________

Status of Patient (Discharged) __________________ Still in Facility (Room #) / Hospital ____________________

Expired ________________ (date and location) __________________________________________________

Complaint Form - Illinois Department Of Public Health