Health Care Facility Complaint Form
Complaint Administration Unit
 
If you think a health care facility may have violated the law relating to your care, or the care of someone you know, please provide as much detail as possible in the boxes below. When completing the “narrative” portion of the form, please include full names of patients/residents, and staff involved. If you know the diagnoses and type of insurance the patient/resident has, please include that. When describing your concern, please include dates of when events happened. Incomplete information may result in no action taken by the Agency. Please understand not all concerns may be actual violations of the law, and rudeness by facility staff is not regulated. After we have reviewed your information, we will send you an e-mail response.
Name of the Health Care Facility:  

To verify that the facility is regulated by our Agency visit www.floridahealthfinder.gov

Please note: practitioners (doctors and/or physician's offices, nurses, dentists, etc.) are regulated by the Department of Health. To visit their site and complete their form go to www.doh.state.fl.us/mqa/enforcement/enforce_csu.html.
Street:
City:  
 Zip:  
Date of Event: (Ex:mm/dd/yyyy)
 
Patient/Resident's Name:
Patient/Resident's Date of Birth:  (Ex:mm/dd/yyyy)
 
Patient/Resident's Insurance:  (ex: Medicare, Medicaid, Private, Uninsured)
Narrative:  
1. Was a specific staff member involved? 
     If yes, please provide their name/position, if you know it. 
2. Was the incident reported to staff? 
     If yes, to whom was it reported? 
3. Have you reported this to other Agencies? Please mark all that apply.




Complainant's identifying information: (The below information is optional.)
Under Florida law, there is no protection of your identity as a complainant, unless you choose to remain anonymous. You will not hear further from us, if you remain anonymous.
Name:
Street:
City:
State:
 		Zip:  
Telephone Day:  
 Alternate:  
Email:  
How did you learn about this form? (ex: Internet search, Friend, AHCA Website, etc.)
 
Thank you for sending us this information. If we determine we have legal authority to do a complaint inspection related to your concerns, we will do so. At that point, a surveyor (inspector) will review the laws that apply to your case, review the written information at the facility, observe care of current patients/residents, and conduct interviews with others receiving care, and staff providing care. The surveyor will determine if the facility is violating any law at the time of the inspection. After that, you will receive notification with the results of the complaint inspection, if we have your contact information.


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Reporting Medicaid Fraud