Patient Grievance Form
Sagent Behavioral Health acknowledges that past and current patients or their authorized representative have the right to voice grievances and recommend changes in policies and services to our staff, free from restraint, interference, coercion, discrimination, or reprisal, including threat of discharge. Please submit this form to file a formal grievance. You have the right to be assisted by an advocate.
Submission Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Information
Patient name
*
Patient date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitted by
*
Relation to patient
*
Email
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Description of grievance
*
Description of your proposed resolution
*
Submit Grievance
Should be Empty: