Online Resident/Patient Care Complaint Form

Michigan Department of Licensing and Regulatory Affairs

Bureau of Health Systems, Complaint Investigation Unit

The Complaint Investigation Unit receives and processes consumer complaints against nursing homes, home health agencies, hospices, hospitals, freestanding surgical units, ambulatory surgical units, and end-stage renal dialysis centers.

All nursing homes are required to post the name, title, location, and telephone number of an individual in the nursing home who is responsible for receiving complaints and conducting complaint investigations. Someone in the nursing home should be on duty 24 hours day, 7 days a week to respond to complaints. You may wish to contact the facility representative or administrator before filing this complaint.

To file your complaint please type information on all sections of this form. Use the navigation buttons to move through each section of the form.

Please call 1-800-882-6006 if you need help completing the form.

Michigan Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this Agency.

RESIDENT INFORMATION

Required fields are marked with an asterisk *

* First Name

* Last Name

Birthdate

Discharge Date
(if no longer in facility)

Date Admitted

Guardian/Resident
Representative

Room #

STEP 1 OF 5

FACILITY INFORMATION

Required fields are marked with an asterisk *

* Name

* Address

* City

State MI

* Zip

Type of Facility

			STEP 2 OF 5

INFORMATION ABOUT PERSON FILING THE COMPLAINT
Required fields are marked with an asterisk *

* First Name (if not resident)	* Last Name
* Address
* City		* State		* Zip
* Daytime Phone	- -		Evening Phone - -
Contact Person (if different)
Other Contact Phone	- -		Evening Phone - -

STEP 3 OF 5

INFORMATION ABOUT YOUR COMPLAINT

Required fields are marked with an asterisk *

*Date of Incident *Time

Have you contacted the facility?

If Yes, person's name

* Type your complaint in the text box below.

Check if you'll be sending additional documents within 5 business days?

STEP 4 OF 5

The Department will not disclose the name of a complainant or the resident named in the complaint during a nursing home investigation without written consent. Sometimes the investigation can proceed more quickly if the complaint can be discussed openly at the time of the investigation. Agreement to disclosure is voluntary and will not affect the acceptance of your complaint.

Do you give permission to release your name and resident's name to discuss the complaint?


To receive a copy of your complaint please enter your email address below.
E-mail Address( (optional)

STEP 5 OF 5