Patient Complaint and Grievance FormPlease share your ICMS experience with us. Fill Out Our Grievance Form Online Here Patient Satisfaction Survey Patient Information Date of Report * MM DD YYYY Patient Name * First Name Last Name Local Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Number * Date of Birth MM DD YYYY Complainant Information Name of person filling out form if other than patient First Name Last Name Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Relationship to Patient Time of Incident * Hour Minute Second AM PM Date of Incident * MM DD YYYY Name of Staff Involved (if known) * First Name Last Name In your own words, please tell us why you are not happy with the care of service you received:? * As a result of your complaint, what would you like to see happen? I understand that staff investigating this complaint may need to see and review health records, but that all information will be kept confidential. I further understand that this complaint/ grievance will in no way affect any care provided. By typing your name here, this certifies as your signature. * First Name Last Name Thank you for taking the time to bring your complaint to our attention. You should receive a response within 10 days. Please complete and submit this form by either mailing, hand delivering, or faxing to ICMS. Download Our Grievance Form Here
