Complete this form if you have concerns about the health care or treatment that you or a family member received or did not receive. Answer all questions. Give complete details. Use as much space as necessary. We will investigate your concerns based on the information that you provide. You may file an anonymous complaint. You may use this form as a guide when making a complaint by telephone. Our complaint hot line Number is (202)442-5833.
Check the type of facility or program:
V. Person or entity filing complaint or reporting incident:
Would you like a report that may result from our investigation?
May we reveal your identity during the investigation of your complaint?
VI. Have you reported this incident or concern to the person in charge of the facility, residence or program?