Division of HIV and STD Programs 600 S. Commonwealth Ave., 10th Floor, Los Angeles, CA 90005Customer Support Form Survey

The Division of HIV and STD Programs’ (DHSP) Customer Support Program aims to assist consumers of HIV and STD services who have experienced difficulty accessing services from DHSP-funded providers throughout Los Angeles County. If you need assistance or have a concern regarding your HIV or STD services that you have not been able to resolve with the provider directly, please feel free to share with us by completing the form below.

To make it as easy as possible, you may submit the completed form by clicking the submit button at the bottom of the form. You can also email us directly at DHSPsupport@ph.lacounty.gov or contact us by phone at (800) 260-8787. Please feel free to reach out with any questions or if you need further assistance.

What happens after I contact DHSP Customer Support Unit?

DHSP staff will contact you regarding your concerns within 2 business days of receipt of your form or message. For questions about services or resources available in Los Angeles County, we will provide you with the information you are requesting and where to go to receive services. For issues or complaints regarding services you have received, we will then work closely with you and can provide assistance with seeking resolutions such as by filing a grievance with the service provider or by providing referrals or information about available services that meet your needs. You will also be welcome to remain anonymous through the process if you prefer.

Your feedback is important to us. Please complete our customer satisfaction survey by clicking the link below:

Customer Satisfaction Survey

YOUR INFORMATION

Yout Name (First, Middle and Last)

Patient/Client Name if different from customer:

Street Address

City

Zip Code

Phone Number

E-mail

Preferred Language

Confidentiality:

Yes

Can we leave a voice message?

Yes

Can we share your name with the agency?

Yes

Preferred Pronouns:

He/Him

She/Her

They/Them

Other (please specify)

For Linkage or Resource Request: Describe assistance that you need.

For Feedback:

TO FILE A COMPLAINT: Fill in the form below and provide as much details as you can.

SERVICE PROVIDER/ AGENCY INFORMATION

Agency Name

Service Location Street Address

City

Zip Code

Did you file a complaint with the agency?

Yes

If YES:

When (date)?

With whom?

What was the result?

COMPLAINT DETAILS:

Please describe your complaint. Attach additional pages or supporting documents as needed.

When did this happen (date of incident)?

Name of person involved?

Name of person witnessed the incident?

What happened?

Attach additional document if any:

No file chosen

Desired Outcome (what would reasonably resolve this concern for you)?

COMPLETE IF AUTHORIZING A REPRESENTATIVE TO FILE A COMPLAINT ON YOUR BEHALF

Name of Representative

Relationship to Patient/Client

Phone Number

Consent:

Yes

Not Applicable

I authorized the person or entity named above to serve as my representative for this complaint.

Yes

Not Applicable

I authorized DHSP staff to assist me with filing a grievance with the service provider (agency).

Yes

Not Applicable