Language
English (US)
Spanish (Latin America)
One Community Health
Patient Complaint or Grievance Form
Para Español, haga clic en el botón de la derecha y seleccione Español.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Method Of Contact
Phone
Email
Mail
Details of Complaint or Concern
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Department:
*
Medical
Dental
Behavioral Health
Lab
Other
Location of Incident:
*
Hood River
Mobile Medical Unit
The Dalles
The Dalles Express Clinic
School-Based Health Center
Stevenson
White Salmon
Staff Member(s) involved (if known):
Describe your concern:
*
Please check one of the following
I have attempted to address my concern and I am not satisfied with the outcome.
I have not attempted to resolve my concern
Please identify how you attempted to resolve your concerns and with whom (if known):
How would you like us to address this concern?
Would you like us to contact you in response to this issue?
Yes
No
Patient Acknowledgement and Information Notice:
I understand my concern will be reviewed to determine whether it is a complaint or a formal grievance involving quality of care, neglect, or unresolved issues.
If classified as a grievance, I will receive a written response within 30 days, with notice if an extension of up to 15 additional days is needed.
I acknowledge that my personal health information (PHI) may be reviewed during this process and will be protected under HIPAA. If submitted on behalf of a patient, information shared with me may be limited without proper authorization.
I understand that submitting a complaint or grievance will not impact the care I receive.
Are you the patient?
*
Yes
No
Legal Guardian or Patient Representative (if applicable)
First Name
Last Name
Signature of Patient (Individual Filing Complaint)
Date Reported
-
Month
-
Day
Year
Date
Signature of Legal Guardian or Patient Representative
Date Reported
-
Month
-
Day
Year
Date
Submit
Should be Empty: