subject_line
Patient Complaint Form
Patient Information
Patient Name
Patient's date of birth
+
Preferred Follow Up Method
Phone
Mail
e-mail
N/A
Person reporting the complaint (if different from patient)
Complaintant Relationship to Patient
Phone Number
*
Email Address
*
Address (Street, City, St, Zip)
*
Complaint Information
Date the incident occurred
*
+
Person Who Received Complaint:
*
Location Where Complaint Reported
*
Acute Clinic
Administration
Bryan High School
Cass Family Medicine
Community Alliance
Heartland Community Health Network
Dental Clinic - LSX
PFA/Marketplace
Indian Hill School
Liberty School
Learning Community Center
LSX FP Clinic
LSX Peds Clinic
NorthWest Clinic (Medical or Dental)
Pharmacy
Spring Lake School
Website
West Omaha (Medical or Dental)
Women's Health Center
WIC
Specific Employee Named In the Complaint?
Department / Roles involved in the complaint (Check all that apply)
*
Behavioral Health (all locations)
TYAHC West
Bellevue
TYAHC South
Acute Clinic
Administration
Behavioral Health
Bryan High School
Cass Family Medicine
Community Alliance
Heartland Community Health Network
Human Resources
Dental Assistant
Dental Clinic - LSX
Dentist
Front Desk / Cashier
Indian Hill School
Liberty School
Learning Community Center
Lab
LSX FP Clinic
LSX Peds Clinic
Medical / Health Assistant
NorthWest Clinic (Medical or Dental)
Nurse
Patient Support
Pharmacy
Phone Staff
PFA/Marketplace
Provider - OneWorld
Provider - Resident/Volunteer
Spring Lake School
West Omaha (Medical or Dental)
Women's Health Center
WIC
Complaint type
*
Access
Billing
Breakdown in Communication
Breakdown in Process
Care / Clinical Quality
Confidentiality
Physical Environment
Interaction with Staff
Wait Time / Efficiency
Other- Be Specific
Other- Be Specific
Brief description of the complaint:
*