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Online Complaint Intake

Fields marked with * are required


Contact Information:

Your First Name
 

Your Last Name
 

Address

 

City
 

State (e.g. PA)

Zip Code (e.g. 17000)
   

Phone Number (e.g. 555-555-5555)
 

Alternate Phone Number (e.g. 555-555-5555)
 

Email
   

Complaint Type

 

Confidentiality

 Confidentiality Requested - will allow DOH to be in touch regarding outcome of investigation, facility will not be informed who lodged the complaint.

Relationship to Patient

 

Please specify if "Other":
 
Patient Information:

Patient First Name
 

Patient Last Name
 


Patient Date of Birth (e.g. MM/DD/YYYY)
   

Date of Incident (e.g. MM/DD/YYYY)
 


Facility Information: 

Facility Name*

Facility Address*

 

Facility City*

Facility State* (e.g. PA)

Facility Zip Code* (e.g. 17000)
 


Complaint Information: 

Concerns discussed with:


Details (Please be as specific as possible)*