Unlicensed Facility Complaint | AHCA - Health Care Facility Complaint Form

Complaint Form for Unlicensed Health Care 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.

To file a complaint about a health care facility that is regulated by the Agency for Health Care Administration, please complete the fields in the complaint form below.

If you prefer to file your complaint about quality of care over the phone, please call us at 1-888-419-3456. Our Call Center is open Monday through Friday, 8am to 5pm, EST.

If you prefer to file your complaint about lack of visitation or other visitation restrictions in a Nursing Home, Assisted Living Facility, Hospital, or Intermediate Care Facility for Individuals with Intellectual Disabilities over the phone, please call us at 1-888-419-3456. Our Call Center is open Monday through Friday, 8am to 5pm, EST.

To verify that the facility is regulated by our Agency, or to view previous inspection reports, visit www.floridahealthfinder.gov

* Indicates a required field.

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.

Complaint Information

Name of the Health Care Facility *

Street *

City *

Zip *

Facility Website

Date of Event

Patient/Resident's Name

Patient/Resident's Date of Birth

Patient/Resident's Insurance (ex: Medicaid, Private, Uninsured)

Narrative * This field does not allow more than 4000 characters. You may upload an attachment if necessary.

Attach Supporting File(s) Individual maximum file size: 10Mb. Acceptable file types are: .doc, .docx, .pdf, .xls, .xlsx, .txt and .wsp

1. Was a specific staff member involved?

Yes

If yes, please provide their name/position, if you know it.

2. Was the incident reported to staff?

Yes

If yes, to whom was it reported?

3. Have you reported this to other Agencies? Please mark all that apply.

Abuse Registry

Law Enforcement

Medicare Fraud

Long Term Care Ombudsman Program

Medicaid Fraud

Other

Complainant's Identifying Information Optional

Note: 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

Email An email copy of this submission will be sent to the email address submitted

Street

City

State

Zip

Telephone Day

Alternate

How did you learn about this form? ex: Internet search, Friend, AHCA Website

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. You will receive notification with the results of the complaint inspection,if we have your contact information.