OAK HHC

Concern / Complaint Report Form

Your voice matters. We use this form to ensure the highest level of care, dignity, and safety for every client and staff member. All submissions are held in confidence.

1. About You

First Name *

Last Name *

Phone Number

We'll never spam you or share your number or email.

Email *

Relationship to Organization *

Preferred Contact Method

Preferred Contact Time

4. Description

Describe the situation *

Who was involved? (if known)

Witness(es) - Name

Contact (optional)

I understand that by submitting this form, I am authorizing Oak HHC to collect and use my Protected Health Information (PHI) for scheduling an appointment and facilitating my care. My authorization is subject to the terms of the Notice of Privacy Practices, which I have received and reviewed.

I authorize OAK HOME HEALTHCARE to collect my PHI as described above.

I consent to be contacted regarding complaint filled. above.

Concern / Complaint Report Form

1. About You

3. Nature of the Concern

4. Description