Complaint Intake Form

Have you already filed a complaint with the State of Michigan, Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification or the Bureau of Community and Health Systems regarding this incident? *

Previous Complaint Information

Do you have your complaint number? It will start with a MI00...

Please provide your complaint number.

Please provide your first and last name that was used when you filed your initial complaint.

Please provide your phone number used when you filed your initial complaint.

Please provide any additional information pertaining to your initial complaint.

Facility Information

Please provide the date and year the incident occurred. *

What time of day did the incident occur (morning, afternoon, etc.)? *

Please select the type of facility involved in this complaint. *

Please provide the name of the facility. *

Please provide the street address and city where the facility is located. *

Please provide the location where the incident occurred (floor, room number, office suite, dining room, etc.). *

Complainant Information

How would you like to file your complaint? *

Please enter your first and last name.

Please select your preferred method of contact.

Please enter your street address.

Please enter your city.

Please enter your state.

Please enter your zip/postal code.

Please enter your phone number.

Would you like to receive text messages at this number?

Please enter your email.

Patient/Resident Information

How do you know the patient/resident? Please select all that apply.

I am the patient/resident
Family
Friend
Visitor
Legal Guardian
DPOA (Durable Power of Attorney)
Provider Staff
Patient Advocate
Other

If you have selected "Other", please specify your relationship with the patient/resident. *

Provide the patient/resident's name and birth year if known. If unknown, please provide a description of the individual to the best of your ability. If you are completing this form for yourself, please put self and birth year as the response. *

Has the complaint regarding this incident been filed with the facility or any other agency/office? *

If you have selected "Other", please specify the type of facility, agency or office.

Were there any witnesses to this incident? *

Please provide the name or description of the witness/witnesses.

How did you learn about this incident? *

Is the patient/resident currently at the facility where the incident occurred? *

Please describe the specific incident that is prompting this complaint including any injuries that resulted. What did the facility fail to do or provide? Only include details to the specific provider named above. If the incident involves multiple facilities, you must file a complaint against each facility. Please limit the complaint details to 300 words or less. *
Examples:

My medications were not given on time, so I was in a lot of pain for a very long time.
Nobody would help me to the bathroom, so I walked on my own and I fell on the floor.
I got an infection at my surgical site while I was in the hospital.
My scheduled service was not provided as ordered.

I acknowledge that the information provided is true to the best of my knowledge.

Yes

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Thank you. The additional information will be included in your complaint investigation.

Complaints greater than one year are not routinely investigated.

Every effort will be used to maintain your confidential information.

If you wish to file an anonymous complaint, you will not receive any information regarding the investigation.