Michigan Attorney General Patient Abuse Complaint Form


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ELDER FINANCIAL EXPLOITATION/PATIENT ABUSE COMPLAINT FORM

(Only New Complaints May Be Filed Online)
Please be aware of the following:

If this matter is an emergency, you should call 911 immediately.
Please also note that the filing of this complaint is not a substitute for contacting Adult Protective Services.
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.

I. RESIDENT/PERSON AT RISK OF ABUSE/EXPLOITATION

Resident Last Name:

* *

Resident First Name:

* *

Gender Identity:

Race:

Date of Birth:

* *

Social Security # (Last 4 digits):

Phone:

Insurance Provider:

Street Address:

* *

City:

* *

State:

Zip Code:

* *

County:

This Address is a:

Facility Name:

Power of Attorney Last Name:

Power of Attorney First Name:

Work Phone:

Guardian/Resident Representative Last Name:

Guardian/Resident Representative First Name:

Work Phone:

Conservator:

Work Phone:

Court Action Pending?

YesNo

Court:

File #:

* (D-123, D. 1-234, ...)

Approximate Monetary Value:

* ($1.50, 150, $1,500)

Incident Date:

* *

Financial Records Attached?

YesNo

Financial Institutions:

Represented by an Attorney?

YesNo

Attorney Name:

Work Phone:

II. IS THE RESIDENT/PERSON A VULNERABLE ADULT: Need assistance with Activities of Daily Living (ADL's)

18 or older

YesNo

Banking/Financial Decisions

YesNo

Bathing

YesNo

Taking Medication

YesNo

Doctor Visits

YesNo

Getting Dressed

YesNo

Cooking

YesNo

Unable to Protect Self

YesNo

Eating

YesNo

Transportation

YesNo

Walking

YesNo

Getting Water

YesNo

65 years or older

YesNo

Sitting

YesNo

Getting out of bed

YesNo

Adjudicated as Incompetent

YesNo

Other

YesNo

Other:

III. PERSON/COMPANY ALLEGEDLY RESPONSIBLE FOR ABUSE/EXPLOITATION

Company or Person?

Last Name:

* *

First Name:

* *

Company Name:

* *

Street Address:

* *

City:

* *

State:

Zip Code:

* *

County:

Phone:

Fax Number:

E-mail Address:

Web Site Address:

Gender Identity:

Race:

Relationship to Resident/Vulnerable Adult:

D.O.B.:

* *

IV. COMPLAINANT INFORMATION (Person filing complaint)

Your Last Name:

* *

Your First Name:

* *

MI:

Title:

Your Street Address:

* *

City:

* *

Your State:

Zip Code:

* *

County:

Phone:

E-mail Address:

* *

Web Address:

Relationship to Resident/Vulnerable Adult:

Firm/Company Name:

Phone:

Firm Address:

Firm City:

Firm State:

Zip Code:

Represented by an Attorney:

YesNo

Name:

Phone:

V. REPORTING

Law Enforcement Notified:

YesNo

Agency:

Police Report #:

Complaint Filed with APS

YesNo

Date:

* *

Complaint Filed with other State Agencies (e.g. MDHHS, LARA BCHS)

YesNo

Agency:

Willing to Testify:

YesNo

Description of Alleged Abuse * * Limited to 24000 characters

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.

Check if this referral is just to give us information and you do not need us to respond to you directly.

Check if you want to send documentation. After you submit this form you will be provided with a postal mail address, and facsimile number, to which you may send documents.

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I certify that the information on this form is true and accurate to the best of my knowledge. *

I consent to releasing to the Michigan Attorney General any information or document relative to the investigation of this complaint. By checking this box, I also certify that I have had the opportunity to review the Michigan Attorney General Privacy Policy before submitting this complaint.

*
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