Online Complaint Form – CINQCARE Health Home

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Complaint form

Contact us at (716) 247-5282

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Complaint form

Do you wish for this complaint to be anonymous?*

Yes

No

First name*

Last name*

Date of birth

MM slash DD slash YYYY

Phone*

Email address*

Address*

Address line 1 Address line 2 City State / provide / region Zip / postal code Country

Relationship to patient*

Affected patient information

First name*

Last name*

Date of birth*

MM slash DD slash YYYY

Diagnosis*

Room #/ floor

Physician name

Is the patient still receiving care or services?*

Yes

No

Complaint information

When did the problem occur?

MM slash DD slash YYYY

Time of day

Hours

:

Minutes

AM/PM

Is the problem ongoing?*

Yes

No

Have you filed this complaint with OHFLAC at an earlier date?*

Yes

No

Do you know if this has happened before to the same individual, or to others?*

Yes

No

Are law enforcement agencies involved?*

Yes

No

Unknown

Where did the problem occur?

Who are the witnesses, if any?

What happened?*

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Conditions appropriate for Health Home Services:

Homelessness
Inadequate housing
Discord with neighbors, lodgers and landlord
Other problems related to housing and economic circumstances
Problems related to living alone
Contact with and suspected exposure to arsenic
Contact with and suspected exposure to lead
Contact with and suspected exposure to asbestos
Illiteracy and low level literacy
Schooling unavailable and unattainable
Failed school examinations
Education maladjustment and discord with teachers and classmates
Other problems related to education and literacy
Problems related to education and literacy, unspecified
Unemployment, unspecified
Change of job
Threat of job loss
Discord with boss and workmates
Other problems related to employment

Unspecified problems related to employment
Unspecified problems related to employment
Lack of adequate food and safe drinking water
Extreme poverty
Low income
Insufficient social insurance and welfare support
Other problems related to housing and economic circumstances
Problems related to housing and economic circumstances, unspecified
Unavailability and inaccessibility of health care facilities
Unavailability and inaccessibility of other helping agencies
Conviction in civil and criminal proceedings without imprisonment
Imprisonment and other incarceration
Problems related to release from prison
Social exclusion and rejection
Other problems related to social environment
Problems related to social environment, unspecified