Patient Grievance Form

Patient Grievance Form
Please complete it to the best of your ability.

This form is to be used by clients of The Damien Center who receive services. The issues that may be addressed in a formal grievance include, but are not limited to, concerns about quality of care, perceived issues with confidentiality, or perceived violations of procedures or policies. Issues regarding complaints submitted by one client in reference to another client’s issues, complaints about other clients, or external agency issues will not be addressed. The client can expect that services will continue to be delivered without disruption, and without reduction in frequency or quality during the grievance process. The client will not be penalized or retaliated against for filing a grievance. The client will have the option to work in conjunction with an advocate of their choosing through the grievance procedures. Clients have the right to withdraw a formal complaint at any time in the process.

A grievance can also be filled out by reaching out to the Grievance Liaison directly by calling 317-632-0123 x 225 or emailing quality@damien.org.

The following agencies may be contacted to report grievances and complaints.

Pharmacy related grievances: Indiana Board of Pharmacy

Mental Health related grievances: Indiana Division of Mental Health and Addiction via their toll-free consumer service line at 800-901-1133

U.S. Department of Health and Human Services
https://www.hhs.gov/ocr/complaints/index.html

HIV Care: Indiana Department of Health’s HIV Services Program HIV Supportive Services Program Manager via email: Supportiveservices@health.in.gov
Today's Date:

MonthDayYear
Date
I do not wish to provide my name.
You are welcome to submit this form without contact information, but that means we cannot follow up with you about the issue or solution.
Chosen Name:
This is the name we will use when communicating with you.
Legal Name*

First NameLast Name
zzzWhat are your pronouns?

He/Him/HisShe/Her/HersThey/Them/TheirsOther
What are your pronouns?

He/Him/HisShe/Her/HersThey/Them/TheirsOther
Date of Birth/Fecha de cumpleaños*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Client's Email Address:*
example@example.com
How would you like to be contacted? (select all that apply)*

PhoneEmail
When is the best time to reach you?
Reason for Grievance:*

Appointment/Access, Medical CareProblem with StaffPolicy/ProcedureBillingLaboratory or Problem with MD, NPReferralDamien PharmacyOther
Which location*

Main Location (26 N Arsenal Avenue)CAFE Location (8902 E 38th Street)3909 (3909 N. Meridian Street)Other
Date of Incident:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name(s) of staff member(s) involved or present*
Briefly describe the incident or concerns: *
Briefly describe your expected resolution to the concern: *
I understand that staff investigating this complaint may need to see and review health records, but that information will be kept confidential. I further understand that this complaint/grievance will in no way affect any care provided.
Name of person completing Grievance Form.

First NameLast Name
Today's Date:*

MonthDayYear
Date
Client's Signature:*

Clear
Please verify that you are human*
Should be Empty: