Grievance Form

Grievance Form

Please fill out the form below to submit your patient grievance.
You have the right to file a complaint with us about our privacy practices or our compliance with our Notice of Privacy Practices, or our Privacy Policies and Procedures. To exercise this right, please complete, sign and date the following form, then submit this complaint to us at:

L&S Consulting Minnesota

Privacy Officer

2042 Wooddale Drive

Suite 250-5029 St. Paul, MN, 55125

651-505-2250, info@lsconsultingmn.com
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of the Grievance
Please be as specific as possible. Include dates, times, staff names, and locations. Use the other side of the form if needed.
Please tell us what resolution you are seeking for this complaint.
Would you like to remain anonymous?

Yes
Should be Empty: