Complaint Form for Unlicensed Facilities
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 information. When describing your concern, please include dates of when events happened. Incomplete information may result in our inability to take action. Please understand not all concerns may be actual violations of the law. In general, incidents older than twelve months do not result in an on-site inspection, though the information is retained in our file. After we have reviewed your information, we will send you an e-mail response explaining the disposition of your complaint.
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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.