Complaint/Concern Form

Complaint/Concern Form
Please complete and send to complaints@aaahc.org

Your complaint/concern will be handled confidentially and while you will receive notification of receipt, the investigation outcomes will not be released due to privacy regulations. Complaints/concerns related to billing or insurance issues are not within AAAHC standards, nor are any labor disputes. AAAHC does not evaluate the care of an individual or whether the care was appropriate. When we investigate, we focus on processes required of a AAAHC-accredited organization necessary to comply with the AAAHC Standards. Before you submit this form, please verify through our “Find an Organization” tool that the organization is accredited by AAAHC.
Today’s Date

MonthDayYear
Date
Date of Incident

MonthDayYear
Date
Complainant Information
Received From (Full Name)
Phone Number
Address

Address

Street Address Line 2

CityState

Postal Code
Facility Information (Required)
Name of Facility*
Facility Type*
Address*

Address

Street Address Line 2

CityState

Postal Code
Provide a Brief Narrative
Include how and why the alleged incident occurred and the individuals involved. This section is limited to 600 Words; continue narrative on next page or attach additional documents, if necessary.
OFFICE USE ONLY
Org ID
MDS Status
Date of Triage

MonthDayYear
Date
Triage Level
Action
Should be Empty: