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PATIENT ABUSE COMPLAINT FORM
 
  (Only New Complaints May Be Filed On-Line)
Please be aware of the following:
  • When your complaint has been submitted, you will be informed of your Web Complaint Number in your confirmation. Please make an accurate record of this number or print the confirmation page.
  • Complaints and inquiries become public records when they are submitted to the Attorney General's office, and under the Michigan Freedom of Information Act, copies may be subject to disclosure to anyone who asks for them.
  • A copy of the complaint may be sent to other governmental agencies.
  • Please be particularly cautious with information containing your Social Security number, credit card account numbers, etc. for security purposes. If you believe it is necessary to submit such information, you should mail that information and the corresponding complaint instead of sending it electronically.
  • Do not use punctuation when providing names and addresses.

NOTE:  Fields labelled in RED are required values.


 
           
   
  Your Last Name:     First Name:     MI:  
  Your Street Address:     City:      
  Your State:   Zip Code:      
  Your County: Your Home Phone:    
  E-mail Address:     Your Work Phone:   Ext:  
  Retype your E-mail:   Fax Number:    
  Your Relationship To Patient:        
 
 
           
 

Resident:

  Resident Last Name:   Resident First Name:    
  Resident Date of Birth:     Resident Social Security No.:    
  Facility:
  Facility Name:     Provider MDCIS No:    
  Street Address:     City:      
  State:   Zip Code:      
  County: Phone:    
  Fax Number:   E-mail Address:    
  Web Site Address:        
  Suspect #1:
  Suspect Last Name:   Suspect First Name:    
  Suspect Position/Title:
  Suspect #2:
  Suspect Last Name:   Suspect First Name:    
  Suspect Position/Title:
  Witness #1:
  Witness Last Name:   Witness First Name:    
  Street Address:   City:    
  State: Zip Code:    
  Home Phone:   Work Phone:    
  Fax Number:   E-mail Address:    
  Witness Position/Title:
  Witness #2:
  Witness Last Name:   Witness First Name:    
  Street Address:   City:    
  State: Zip Code:    
  Home Phone:   Work Phone:    
  Fax Number:   E-mail Address:    
  Witness Position/Title:
 
 
           
  Incident Date:     Incident Time: :
  Incident Location:  
  Are you willing to testify in court regarding this complaint?
  Did you complain directly to the facility?   If so, who?  
  What was the response from the facility?    
  If no complaint was given to the facility directly, why?    
  Was this complaint filed with any other agencies? (Including MDCH) If so, who?  
 
  Description of Alleged Abuse    
 

Please provide any additional relevant information in chronological order, including dates, names, addresses, telephone numbers, and account numbers where possible. You have approximately 8-10 typed pages and you may paste text from word processing documents.

 
           
 
 
 
 
 
   
   
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