Heart And Solutions, LLC.
Grievances
Client Name
First Name
Last Name
Name of person completing this form
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Description of the concern:
*
Requested Resolutions:
*
I understand that my written concern will be reviewed and investigated internally
I request that my concern be reviewed by the Heart and Solutions, LLC compliance board at their next quarterly meeting (January, April, July, October)
*
I understand that all team members and/or contractors such as, but not limited to, board members, who might review this concern have signed confidentiality agreements to keep my personal health information protected
Submit
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