Consumer Complaint Form - Missouri Department Of Health And Senior Services printable pdf download

Consumer Complaint Form - Missouri Department Of Health And Senior Services

Missouri Department of Health and Senior Services

Bureau of Health Services Regulation

PO Box 570

Jefferson City, MO 65102

Phone: 573-751-6303 or Fax: 573-526-3621

All information is confidential.

CONSUMER COMPLAINT FORM

Name:

Address:

Email:

Phone: (home)

(work)

(cell)

Patient’s Name:

Patient’s Date of Birth:

How are you related to the patient?

Facility Name:

Facility Address:

Date patient admitted:

Date patient discharged:

Patient room number, floor or unit if known.

Did patient go to the Emergency Room?

If so, via ambulance or private vehicle?

What problems/symptoms was the patient experiencing that caused the patient to seek care at this facility?

Have you spoken to anyone at the facility regarding your concerns? If so, who did you speak with?

What action do you want taken by our agency?

Please explain fully what your concerns are.

By filing this complaint, I understand that:

The Missouri Department of Health and Senior Services does not act as my attorney nor sue hospitals on my behalf.

The DHSS enforces state and federal regulations and has authority only as limited by these regulations.

Consumer Complaint Form - Missouri Department Of Health And Senior Services