Clinical Complaint Submission

Client Grievance Type*

Select

Patient Name*

First, Last Name

Patient DOB *

Patient Phone #*

Phone

Description*

Please add as much detail about the issue here. We may reach out to obtain additional specifics after submission.

File Upload

Please drag and drop any supplemental documents associated with the complaint. This intake form is HIPAA compliant.

Drag and drop files here or

Client Location*

Please enter your organizations name

Client Contact Phone Number*

Phone

Client Contact Email*

Send me a copy of my responses