Complaint Report Form - Maryland Department Of Health printable pdf download

Complaint Report Form - Maryland Department Of Health

MARYLAND

Department of Health

Office of Health Care Quality

Spring Grove Center • Bland Bryant Bldg. • 55 Wade Avenue • Catonsville, MD 21228 • 410-402-8015

COMPLAINT REPORT FORM

Complete this form if you have concerns about the health care or treatment that you or a family

member received or did not receive. Answer all questions. Give complete details. Use additional sheet,

if necessary. You may use this form as a guide when making a complaint by telephone. We will

investigate your concerns based on the information that you provide.

You may file an anonymous complaint

Complete the following questions.

I. Name of patient/resident/client involved in the incident: ___________________________________

Sex: [] Male

[] Female Age: _____

II. Health care facility, residence, or community treatment program involved in the incident:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

Check the type of facility or program: [] Nursing home [] Adult medical day care [] Assisted living

[] Hospital [] Home health agency [] Residential treatment center [] Hospice [] Dialysis Center

[] HMO [] Ambulatory surgery center [] Residential services agency [] Birthing center

[] Medical laboratory [] Developmental disabilities provider [] Other. Please specify

__________________________________

III. Witnesses to the incident:

Name

Contact information, if known (include telephone number)

_______________________________ ____________________________________________________

IV. Person filing complaint or reporting incident (optional). Note: If you would like a deficiency

report that may result from our investigation, please complete this section.

Name: ______________________________________________ Relationship: ____________________

Address: ___________________________________________________________________________

Telephone: _____________

May we reveal your identity during the investigation of your complaint? [] Yes

[] No

Complaint Report Form - Maryland Department Of Health