Complaint / Grievance Log

Use this form to report a concern about the services, staff, billing, privacy, or accessibility of High Quality Care Nursing Agency, Inc.

Your rights

You have the right to file a complaint without fear of retaliation.
You may submit anonymously, though anonymous submissions limit our ability to follow up.
If your concern involves immediate danger, call 911. For urgent clinical concerns, call us at (301) 617-9315.
Information is kept confidential and shared only with personnel needed to investigate.

Submit anonymously (we will not be able to contact you for follow-up)

Your Information

Full Name *

Relationship to Patient/Client

Phone Number

Email Address

Mailing Address

Preferred Method of Contact

Patient / Client Involved

Complete this section if the complaint involves a patient or client other than yourself. Leave blank if not applicable.

Patient / Client Name

Date of Birth

Medical Record # (if known)

Complaint Details

Date of Incident *

Time of Incident (approx.)

Location of Service

Category *

Severity (your assessment)

Staff Member(s) Involved (if known)

Witnesses (if any)

Describe What Happened *

What outcome or resolution are you seeking?

Have you reported this elsewhere?

Acknowledgement & Signature

I authorize High Quality Care to access and review records related to this complaint (including protected health information) for the limited purpose of investigation and resolution, in accordance with HIPAA and applicable privacy laws.I understand that High Quality Care prohibits retaliation against anyone who files a complaint in good faith, and that the information I provide will be kept confidential to the extent permitted by law. *

Signature (type full name) *

Date