• Client or Stakeholder Complaint/Grievance

  • Complaint/Grievance Details

  •  - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Desired Outcome

  • Follow-Up Preferences

  • Until

  • Because you set the option to remain anonymous, we will not be able to follow-up with you regarding this complaint.

  • Additional Comments or Information

  • Consent/Agreement

    • Confidentiality Assurance:
      We are committed to protecting your privacy and maintaining the confidentiality of all information provided in this complaint form. Your complaint will be handled in accordance with applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) in the United States. Any personal or health information shared will only be used for the purpose of addressing your complaint and will not be disclosed to unauthorized individuals. 
    • No Retaliation Policy:
      We take all complaints seriously and are committed to addressing them in a fair and thorough manner. Retaliation against individuals who submit complaints in good faith will not be tolerated. You have the right to file a complaint without fear of retaliation, discrimination, or any adverse action. Any instance of retaliation will be promptly investigated and dealt with according to our policies.
       
      By submitting this form, you consent to the collection and review of your information in a secure and confidential manner.
       
  • Should be Empty: