MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
RECIPIENT RIGHTS COMPLAINT
|INSTRUCTIONS: |
|If you believe that one of your rights has been violated, you (or someone on your behalf) may use this form to make a complaint. A staff person from the Office of|
|Recipient Rights will review the complaint and may conduct an investigation. Keep a copy for your records and send the original to the Office of Recipient Rights |
|at: |
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|Office of Recipient Rights |
|Genesee Health System |
|420 West Fifth Avenue |
|Flint, MI 48503 |
|(810) 257-3710 phone |
|(810) 257-3790 fax |
|Complainant’s Name: |Recipient’s Name (if different from complainant): |
|Complainant’s Address: |Where did the alleged violation occur? |
|Complainant’s Phone Number: |When did the alleged violation happen? (date and time): |
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|What right was violated? |
|Describe what happened: |
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|What would you like to have happen in order to correct the violation? |
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|Complainant’s Signature |Date |Name Of Person Assisting Complainant |
|DCH 0030 Replaces DCH-2500 Authority: P.A. 258 of 1974 as |
|amended |
|Distribution: ORIGINAL TO ORR |
|COPY to Complainant (with acknowledgement letter) |
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Complaint Number
Category
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