Patient Complaint/Comment Form

INSTRUCTIONS:
The Family Health Centers, Inc works to ensure that all patients get the best care possible. We take your concerns seriously and would like to get additional information to help us with your complaint. All patient complaints are confidential. Our complaint resolution process begins with the gathering of important information from all involved parties. Provide as much information as possible. All complaints will be given serious attention. This patient complaint form will be forwarded to the appropriate Manager, who will directly address your concerns.

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* 1. PERSON MAKING COMPLAINT

Name

Company

Address

City/Town

State

ZIP Code

Email Address

Phone Number

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* 2. Your Relationship to the Patient

Self

Parent

Son/Daughter

Spouse

Brother/Sister

Friend

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* 3. What is a good time to reach you

Morning (9am to 12pm)

Afternoon (12pm to 6pm)

Evening (6pm to 8pm)

NATURE OF COMPLAINT:

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* 4. Date of Complaint

Date

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* 5. Time of Complaint

Date / Time

Time

AM/PM

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* 6. Staff Involved (Name/Title):

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* 7. Site Involved (Location):

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* 8. Department Involved:

Provider

Administration

Nursing

Dental

Radiology

Lab

Care Coordination

Patient Services

Front Desk

Call Center

Other (please specify)

Description of Complaint

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* 1. PERSON MAKING COMPLAINT

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* 2. Your Relationship to the Patient

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* 3. What is a good time to reach you

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* 4. Date of Complaint

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* 5. Time of Complaint

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* 6. Staff Involved (Name/Title):

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* 7. Site Involved (Location):

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* 8. Department Involved:

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* 9. Describe problem or reason for Complaint: