Concerns and Grievance Form
Our team actively works to provide the most efficient and optimal experience for providers and patients. We develop comprehensive policies and procedures to support this effort. However, there may be times provider or patient experiences are less than optimal. When this happens, we encourage the affected individual to openly communicate their concern and collaborate to create an satisfactory outcome. When this cannot be achieved, we encourage individuals to use this form to submit a complaint, concern, or grievance. Upon submission, a team member will review relevant information and respond within 14 days.
Please tell us about yourself and your relationship to our program.
Organization Relationship
I am the patient
I am the parent of the patient
I am an outside provider
I am a current staff member or provider for the organization
I am an advocate (external representative with signed ROI on file)
Other
Are you filing the complaint for yourself or on behalf of a patient?
For Myself
On Behalf of a Patient
For Information Only
Your Name
First Name
Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list the names of other individuals involved in this concern, complaint, or grievance?
Are the individuals listed above aware of your concern, grievance, or complaint?
Yes
No
We understand that some concerns require discretion. To support a full resolution, may we share the details of your concern with the staff member(s) involved?
Yes, I’m comfortable with this
Yes, but please keep my identity confidential
No, I prefer not to share this with the staff member
Please describe the status of your concern
The concern has been resolved
The concern is active and ongoing (Follow up Required)
The concern is to help prevent a more serious issue (Information Only)
The concern is for information only (Information Only)
The concern is to help improve the clinic's internal practices (Information Only)
Other
Please provide an approximate date range of the occurence
Please describe what happened
To your knowledge, please describe what action has already been taken to address this concern, complaint, or grievance
In your opinion, what would be helpful in resolving this concern, complaint, or grievance?
Please upload any supporting documentation
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