MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
|MICHIGAN DEPARTMENT OF COMMUNITY HEALTH |COMPLAINT NUMBER |CATEGORY |
|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 RIGHTS OFFICER/ADVISOR WILL |
|REVIEW THE COMPLAINT AND MAY CONDUCT AN INVESTIGATION. KEEP THE PINK COPY FOR YOUR RECORDS AND SEND THE OTHER COPIES TO THE RIGHT OFFICE AT YOUR CMH SERVICES |
|PROGRAM, HOSPITAL, OR TO: MICHIGAN DEPARTMENT OF COMMUNITY HEALTH |
|OFFICE OF RECIPIENT RIGHTS |
|LEWIS CASS BUILDING |
|LANSING, MI 48913 |
|COMPLAINANT’S NAME |RECIPIENT’S NAME (If different from complainant) |
| | |
|WHERE DID THE ALLEGED VIOLATION HAPPEN? |PHONE NUMBER |
| | |
|COMPLAINANT’S ADDRESS |WHEN DID IT HAPPEN? (Date and time) |
| | |
| |
|WHAT RIGHT WAS VIOLATED? |
| |
|DESCRIBE WHAT HAPPENED |
| |
|WHAT DO YOU WANT TO HAVE HAPPEN IN ORDER TO CORRECT THE PROBLEM? |
| |
|COMPLAINANT’S SIGNATURE |DATE |NAME OF PERSON ASSISTING COMPLAINANT |
| | | |
DCH-0030 2/97 REPLACES DCH-2500 AUTHORITY: P . A. 258 OF 1975 AS AMENDED BY P.A. 290 OF 1995
DISTRIBUTION: ORIGINAL – ORR COPY FOR – Provider COPY FOR – Complainant
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