Office of Health Care Quality - Complaint Form

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

No

Facility or Program

Type of Facility or Program*

Adult Medical Day Care

Ambulatory Surgical Center

Assisted Living Program

Assisted Living Referrers

Clinical Laboratory

Cosmetic Surgery Facilities

Developmental Disabilities

Dialysis Center

Federally Qualified Health Centers

Forensic Residential Centers

Freestanding Medical Facilities

Health Care Staffing Agencies

Health Maintenance Organizations

Home Health Agency

Hospice

Hospice Houses

Hospital

Hospitals within Correctional Facilities

Intermediate Care Facilities for Individuals with Intellectual Disabilities

Limited Hospice Care Programs

Limited Private Inpatient Facilities

Major Medical Equipment Providers

Nurse Referral Staffing Agencies

Nursing Home

Outpatient Physical Therapy Providers

Portable X-Ray Providers

Residential Service Agency

Residential Treatment Center

Rural Health Clinics

Surgical Abortion Facilities

Transplant Centers

Other

What is the address of the residential or day program?

What date was the patient was admitted to the hospital?

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

No

Unknown

Witness Information

Was there a witness to the incident?

Yes

No

Unknown

What is the witness's name?

What is the witness's phone number?

Phone

What is the witnesses email address?

Please attach any additional information below:

Drag and drop files here or

Send me a copy of my responses

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