Patient Complaint Form To the Patient: You have the right to file a complaint with us about our privacy practices or our compliance with our Notice of Privacy Practices, our Privacy Policies and Procedures, or federal or state privacy rules or law. Patient Lodging ComplaintName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Patient's ComplaintPlease give a concise, plain statement of your complaint.(Required)Please give a concise, plain statement of the resolution you seek for your complaint.(Required)Consent(Required) I certify that the statements made in this complaint are true and correct to the best of my information and belief.Signature(Required)Today's Date(Required) Month Day Year This Complaint may be signed on behalf of the patient by a personal representative who completes the following:Personal Representative's Name First Last Relationship to Patient YOU ARE ENTITLED TO A COPY OF THIS COMPLAINT.EmailThis field is for validation purposes and should be left unchanged.
