This complaint form is provided freely for use by the general public. HPA does not take any position on any particular hospice agency. The information which may be filled-in here solely reflects the allegations of the individual(s) signing this form.

COMPLAINT FORM



U.S. Mail certified no.   ________________________________________
(Sent certified and return receipt mail)


Date complaint sent:   _______________________________________


To:      (Name and address of government agency):
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________
From:    (name and address of person(s) making complaint)
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________
  • (Home tel. no.)    ______________________________
  • (Work tel. no.)    ______________________________

Re: Name of hospice  ___________________________________________________________
(Address of hospice): 
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________
  • __________________________________________________________________

Tel. no. of hospice:    ____________________________________

Re: name of patient  ____________________________________
Patient date of birth:   __________________________________________
Patient's hospice ID. no.   ______________________________________
(Medical record no. if known)

Date patient admitted to hospice program:  __________________________________________

Date patient discharged from hospice:   __________________________________________
(Date of discharge from program and/or date of death)
Terminal diagnosis:   ____________________________________________________________
Exact location (address and room)where problem(s) occurred:
  • __________________________________________________
  • __________________________________________________
  • __________________________________________________
  • __________________________________________________

Name of patient's attending physician:   __________________________________________
Attending physician's address:   _________________________________________________
  • __________________________________________________
  • __________________________________________________
  • __________________________________________________
  • __________________________________________________

Attending physician's telephone no.   ____________________________________________

Name of hospice RN Case manager:   ____________________________________________

Number of separate complaints/problems (allegations or issues) to government agency:
________(use numeral here)   ____________________________(number spelled out)




1. Brief description of complaint problem/allegation number 1:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Approximate date(s) this problem occurred:_________________
A more detailed description is attached: Yes ____ No ____


2. Brief description of complaint problem/allegation number 2:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Approximate date(s) this problem occurred:_________________
A more detailed description is attached: Yes ____ No ____


3. Brief description of complaint problem/allegation number 3:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Approximate date(s) this problem occurred:_________________
A more detailed description is attached: Yes ____ No ______


4. Brief description of complaint problem/allegation number 4:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Approximate date(s) this problem occurred:_________________
A more detailed description is attached: Yes ____ No ____


5. Brief description of complaint problem/allegation number 5:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Approximate date(s) this problem occurred:________________


There are more than five (5) problem areas, and
descriptions of other problems are attached: Yes _______ No _______


The total number of complaint/problem areas to be investigated is:
______ (numeral) ____________ (number spelled out)

Number of total pages in this complaint:   ________________________________________




____________________________________________ Date signed:______________________
(Signature of person making complaint)


____________________________________________ Date signed:______________________
(Signature of person making complaint)


____________________________________________ Date signed:______________________
(Signature of person making complaint)



(Keep a copy of this complaint and the U.S. post office's proof of certified mail/return receipt card for your records!)

All material copyright of Hospice Patients Alliance ("HPA") unless otherwise credited.