Complaint/Grievance Form

Complaint/Grievance Form

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 or print and mail this complaint to us at:

Emerald Therapy Center, LLC

Jake Allen, COO

5050B Village Square Drive

Paducah, KY 42001

270-534-5128

j.allen@emeraldtherapycenter.com

You may in addition or in the alternative to filing a complaint with us, file a complaint with the United State Department of Health and Human Services.
Name*
Address*

Address

Street Address Line 2

CityState / Province

Zip
Telephone*
Email
example@example.com
Social Security Number
Please provide a detailed description of your complaint:*
Please tell us what resolution you are seeking for this complaint:*
Name of Client/Parent/Guardian*
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty: