COMPLAINT FORM - Utah Department of Health
NAME
UTAH DEPARTMENT OF HEALTH BUREAU OF LICENSING AND CERTIFICATION
COMPLAINT FORM
PO BOX 144103 SALT LAKE CITY, UT 84114-4103
(801) 273-2994 (800) 662-4157 toll free
(801) 274-0658 Fax HealthFacilityComplaint@
PHONE NUMBER
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP
ANONYMOUS: By choosing to remain anonymous you will not be able to inquire the status of the investigation nor will you receive any results of the investigation.
FACILITY/PROVIDER INFORMATION
FACILITY/AGENCY NAME
ADDRESS
RESIDENT INFORMATION
RESIDENT/PATIENT NAME
DATE OF BIRTH
RELATIONSHIP TO RESIDENT
COMPLAINT INFORMATION
Is the resident still in the facility or receiving services through the agency?
YES
If the incident occurred in a hospital emergency room was the patient
admitted to the hospital from the emergency room?
YES
Have you reported your concerns to any other agencies? APS OMBUDSMAN
Have you spoken with anyone at the facility/agency regarding your concerns?
YES
NO NO LAW ENFORCEMENT NO
If yes , who did you speak with and has there been any change?
Provide as much information as possible regarding your concerns including date(s), time, names of all individuals involved and their titles, names of witnesses and their contact information, where the incident(s) occurred, etc. Select the box below if you need to attach additional pages of supporting documentation. The response and timing of any investigation by the State Agency will be based upon the information you provide.
Additional documentation will be attached to my complaint.
Version: 04/15/2022
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- new york state department of health complaint form
- hhs office for civil rights complaint form package
- complaint form utah department of health
- sutter health plus
- michigan local health department and county
- complaint report form complete the following questions
- state of illinois illinois department of public health
Related searches
- nevada department of health license
- colorado department of health and human services
- nevada department of health licensing
- department of health complaint hotline
- virginia department of health office of licensure
- utah department of education licensing
- utah department of education licensure
- utah department of education website
- department of health bureau of vital records
- state of florida department of health license
- florida health department of health website
- utah department of education standards