Confidential Patient Grievance Form

Grievance form

This form is to be used to file a formal grievance. All sections must be completed and will serve as the source document for the grievance process (attach additional pages if more room is necessary). Please answer all questions fully. All supporting documentation must be attached to this grievance form at the time the grievance is filed. Additional information may be requested as necessary and must be provided within 15 days. The grievance will be terminated with no resolution if we do not receive the requested document.

The grievance is a process that may involve multiple offices and thus requires time. Due to the sensitivity of this document, due process is necessary; a grievance can take anywhere from 30 days up to 180 days, depending on how fast we receive any documents from third parties (if any). The form below is a confidential form where you can write down any problems or concerns you have. 

Please be as accurate as you can when indicating the source of your concerns. The confidential grievance form is significant for several reasons:

Firstly, it ensures your privacy. Whatever you write on this form remains confidential unless you decide to share it with others. Your concerns are kept private, so you can speak up without worrying about anyone else knowing.
Secondly, it acts like a record keeper. Just like a diary, it notes down your problem. This helps the people in charge remember all the issues and work on fixing them systematically.
Thirdly, it promotes fairness. No matter who you are, this form ensures that everyone is treated the same way. It levels the playing field, allowing anyone with a problem to use it to report their concerns.
Moreover, it’s a problem solver. When those in charge review these forms, they can take steps to make things better. They investigate the issues and find solutions to resolve them.
Lastly, it empowers you. Using this form ensures that your voice is heard and that your concerns matter. It’s a way of feeling respected and valued in your relationship with us, regarding any service you are using.