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PRINTED: 06/06/2022 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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Review the complaint form and make sure all sections are filled out completely

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What is form investigation of complaints?

The form investigation of complaints is a document used to formally report and investigate grievances or complaints related to a specific issue, such as services, products, or regulatory compliance.

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Individuals or entities that have a grievance or complaint regarding a service, product, or compliance issue are required to file this form.

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To fill out the form, provide detailed information about the complaint, including personal information, a description of the issue, any evidence or documentation, and signatures as required.

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The purpose of the form is to ensure that all complaints are formally documented, facilitating an appropriate investigation and resolution process.

What information must be reported on form investigation of complaints?

The form must report personal details of the complainant, a description of the complaint, dates and locations relevant to the complaint, and any supporting evidence.

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