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 this complaint to us at: You First Health Systems 4325 Forbes Boulevard, Suite E, Lanham, MD 20706 Email: info@youfirsthealthsystems.com Phone: 301-329-0177 Fax: 240-547-0525

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

Address

Street Address Line 2

CityState / Province

Zip
Phone
Email
example@example.com
Please provide a detailed description of your complaint
Please tell us what resolution you are seeking for this complaint
Name of ClientParentGuardian
Date

MonthDayYear
Date
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