Office of Health Care Quality - Complaint Form

The Maryland Department of Health (MDH): Office of Health Care Quality (OHCQ) licenses health care facilities and community-based programs.

This form is used to submit a complaint about a facility or program to OHCQ.

Individual Filing the Complaint

Enter your name

Enter your street address, city, state, and zip code

What is the best phone number to reach you?

Phone

What is your email address?

May we reveal your identity during the investigation?

If you check "no: below, OHCQ will not reveal your identity to the facility. If there is a future legal appeal related to this investigation, your name may become known during the court hearing.

Yes

Facility or Program

What is the name of the health care facility or program related to your complaint?

What is the address of the facility or program?

What is the phone number of the facility or program?

Phone

Patient Information

What is the full name of the patient involved in the complaint?

What is the patient's date of birth or approximate age?

Description of Incident or Concerns

What is the date of the incident or concern?

Please describe the incident or concern below:

Did you report this incident or concern to the facility or program?

Yes

Unknown

Witness Information

Was there a witness to the incident?

Yes

Unknown

Please attach any additional information below:

Drop your files here

Send me a copy of my responses

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