Website Patient Complaint

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 NameLast Name
MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Legal Guardian or Patient Representative (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone Number (if different than patient's)*
Please enter a valid phone number.
Email
example@example.com
Email (if different than patient's)
example@example.com
Preferred Method Of Contact

PhoneEmailMail
Details of Complaint or Concern
Date of Incident*

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Department:*

MedicalDentalBehavioral HealthLabOther
Location of Incident:*

Hood RiverMobile Medical UnitThe DallesThe Dalles Express ClinicSchool-Based Health CenterStevensonWhite 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
Type of Complaint*

TreatmentCommunicationAccess to CareBillingSchedulingStaff InteractionOther
I would like a call to discuss this complaint::*

Yes, please call me.No, I do not want a call.
Person Reporting Incident:*

First NameLast Name
Relationship to patient: type here
I have attempted to address my concern and am not satisfied with the outcome. Please identify how you attempted to resolve your concerns, with whom, and the reason you are not satisfied:I have not attempted to resolve my concern because:
Please identify how you attempted to resolve your concerns and with whom (if known):
How do you suggest the complaint be resolved?
How would you like us to address this concern?
Please identify how you attempted to resolve your concerns and with whom (if known).
Would you like us to contact you in response to this issue?

YesNo
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?*

YesNo
Signature of Patient (Individual Filing Complaint)

Clear
Date Reported

MonthDayYear
Date
Signature of Legal Guardian or Patient Representative

Clear
Date Reported

MonthDayYear
Date
TYPE OF CONCERN (Please check one):*

Patient ComplaintPatient Grievance
Should be Empty:

One Community Health

Patient Information

Details of Complaint or Concern

Patient Acknowledgement and Information Notice: