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Patient Grievance Form
Formal complaint form for patients to report concerns about quality of care, safety, billing, or patient rights violations at a healthcare facility.
PDF TemplateUse the instructions below to complete this form
Instructions
Describe the incident or concern in detail, including dates, locations, and individuals involved. State the resolution you are seeking. Hospitals participating in Medicare must have a grievance process meeting CMS Conditions of Participation. The facility must acknowledge the grievance and provide a written response within a reasonable timeframe. You may also file complaints with your state health department or The Joint Commission.