CARE: Member Grievance Form

C.A.R.E. Form: R9-10-1003-C-2-J

Concern And Resolution Evaluation: Member Grievance Form for Member Concern and Resolution

Area: Administrative Services

Policy: 12VAC35-105-490

Page: 1 of 1

Title: Summit Behavioral Health of AZ DBA Graniter Mountain BHC - Grievance

Focus: Written Grievance Policy - Grievance Form

Issued: 03/15/2017

Revised: 02/10/2021

Welcome to the member C.A.R.E. Form System, also known as the Member Grievance Resolution Form

At Granite Mountain Behavioral Healthcare, we value your feedback and are committed to addressing any concerns or recognizing positive experiences you may have. Our C.A.R.E. Form (Concern and Resolution Evaluation) provides a platform for you to share not only issues, suggestions, or grievances, but also affirmations and appreciation related to your experience. We strive to offer prompt and effective resolutions to support your well-being and recovery journey.

By submitting this form, you can express any concerns, suggestions, or positive feedback about your care, interactions with staff or other members, and facility conditions. Whether it’s a complaint, suggestion, appreciation, or general feedback, your input helps us improve our services and ensures that your voice is heard.

Please Note: If the incident involves another member or patient at Granite Mountain BHC, please do not include their full name in the description. Instead, use their first name and last initial, or just their initials, to help protect their privacy and yours. Thank you for your cooperation.

Please fill out the information below:

I. Member Information:
1. Name of member submitting this CARE form: (Optional: if you want this to be anonymous please leave blank)

First NameLast Name
2. (Optional) E-mail you can be contacted at:
example@example.com
3. Todays Date/Submission Date*

MonthDayYear
Date
4. What is your current Level of Care?*

Residential level of care (Willow Lake RTC)Transitional/IOP level of care (Florentine)Outpatient Program level of carePast Member - Not currently enrolled in services but has been in the pastOther
II. Event Information
1. Please select the type of CARE submission that best describes your concern:*

SuggestionFeedbackComplaint/GrievanceQuality ConcernRequest for assistanceAffirmation/AppreciationOther
2. Please select the department most relevant to your concern:*

Facilities/Housing IssueMedication/MedicalClinical/TherapyCase ManagementPeer Support/Employment ServicesAdministrative/OfficeAdmissions/IntakeOther
3. Date and approximate time of the event or concern:*

MonthDayYear
Date
Hour MinutesAM/PM Option

4. NAME OF OTHERS INVOLVED: List the first name and LAST INITIAL ONLY of all individuals involved, their role (e.g., witness, involved party), and whether they are a patient or staff. Include any relevant notes if necessary. If no one else is involved, please leave blank.

	NAME (First name and LAST INITIAL ONLY or Initials only)	Participation Type:	Patient or Staff?	Notes (if needed) .
1. Person #1:
2. Person #2
3. Person #3:
4. Person #4:
5. Person #5:

5. Please provide a detailed description of your concern or incident: PLEASE NOTE: As described above, please DO NOT USE FULL NAMES of members/patients. Use only First name and last initial or Initials. *
(PLEASE NOTE: Please DO NOT USE FULL NAMES of members/patients. Use only First name and last initial or Initials.)Include any relevant information to help us understand the issue. DO NOT USE FULL NAMES of members/patients. Use only First name and last initial or Initials.
6. What resolution or action would you like to see, or what could we do better?
While we cannot guarantee specific actions, your input helps guide our response.
III. Conclusion and Signature:
1. HIPAA Acknowledgment:
Please note that while this form is HIPAA compliant and your submission is securely protected and encrypted, any follow-up communication may occur via unencrypted email, which poses a risk that your personal information could be accessed by unauthorized parties. While your form submission is encrypted, email correspondence is secure but unencrypted, meaning it does not offer the same level of protection. If you prefer not to receive email communication, please select "No" below. If you agree to receive email correspondence, please select "Yes."
2. Do you acknowledge and consent to receiving follow-up communication via unencrypted email, understanding the associated risks?*

Yes - I voluntarily consent to receive follow-up communication via secure but unencrypted email and I understand the risks.No - I do not wish to receive updates or replies via email and will await direct communication in person.
3. SIGNATURE: (Optional- If you wish to be contacted directly, please sign your name below. You may also remain anonymous by leaving this field blank. By signing, you confirm that the information provided is accurate to the best of your knowledge.

Clear
Note: Please allow 72 hours for this form to be reviewed.
4. Print Name (Optional- If you wish to remain anonymous, please leave blank.)

First NameLast Name
Should be Empty:

C.A.R.E. Form: R9-10-1003-C-2-J

I. Member Information:

II. Event Information

III. Conclusion and Signature: