Complaint Report Form - Maryland Department Of Health (Page 2 of 2) in pdf

Complaint Report Form - Maryland Department Of Health Page 2

V. Briefly describe the incident or your concerns (use additional paper if necessary):

Include dates and times, persons involved, and description of what happened. Include attachments, if

appropriate. Note: If this is an anonymous report, be complete since we will not be able to contact you to

obtain missing information.

VI. Have you reported this incident or concern to the person in charge of the facility, residence or

program?

[] Yes

[] No

Address written complaints to the appropriate licensing unit (listed below) and mail to:

Office of Health Care Quality

Spring Grove Medical Center

Bland Bryant Building

55 Wade Avenue

Catonsville, Maryland 21228

Or submit your complaint to the appropriate OHCQ licensing unit phone:

Nursing homes- (410) 402-8108 Toll-free 877-402-8219

Hospitals- (410) 402-8016 Toll-free 877-402-8218

Health maintenance organizations- (410) 402-8016 Toll-free 877-402-8218

Developmental disabilities programs- (410) 402-8094 Toll-free 877-402-8220

Assisted living homes- (410) 402-8217 Toll-free 877-402-8221

Clinical laboratories- (410) 402-8025 Toll-free 877-402-8202

Home health agencies, hospice programs, residential service agencies, kidney dialysis centers-

(410) 402-8040 Toll-free 800-492-6005

Adult day care- (410) 402-8125 Toll-free 877-402-8221

8/2016

Complaint Report Form - Maryland Department Of Health Page 2