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 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 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
