Patient Grievance Form

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

Purpose of this form:

This form is for clients of Damien Center who would like to submit a formal grievance regarding the services they have received. You can use this form to report concerns such as:
- Quality of care
- Confidentiality issues
- Violations of policies or procedures
Please note:
- Grievances about other clients or external agencies cannot be addressed through this form.
- Filing a grievance will not affect your services, care frequency, or service quality.
- Damien Center prohibits any retaliation for submitting a grievance.
- You may choose an advocate to support you during the grievance process.
- You can withdraw your grievance at any time.
Other Ways to File a Grievance:

You may also contact our Grievance Liaisons directly:
- Call 317-632-0123, extension 225 or 244
- Email: quality@damien.org
- Submit online: https://www.damien.org/contact/grievances
External Reporting Options:

Pharmacy:
- ACHC Accreditation: (855) 937-2242 or https://www.achc.org/Contact/
- Indiana Board of Pharmacy: (317) 232-6201 or https://www.in.gov/pla/file-a-complaint/
Mental Health and Substance Use Treatment:
- Indiana Division of Mental Health and Addiction: (800) 901-1133
- Indiana Disability Rights: (800) 622-4845 or info@IndianaDisabilityRights.org
Civil rights or health privacy violations:
- U.S. Department of Health and Human Services, Office of Civil Rights: (877) 696-6775 or https://www.hhs.gov/ocr/complaints/index.html
HIV Care:
- Indiana Department of Health – Division of HIV, STI, Viral Hepatitis: supportservices@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

MonthDayYear
Phone Number
Please enter a valid phone number.
Client's Email Address:
example@example.com
The Grievance Liason may connect with you through your provided email. These emails will sometimes go to your junk mail. Please check your junk mail if you have not heard from the Grievance Liason within 2 business days.
Preferred contact method (select all that apply)

PhoneEmail
Is it okay to leave a voicemail at the number you listed?

YesNo
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*

Mosaic, Main Location (1420 E. Washington St.)Legacy (26 N Arsenal Avenue)Other
What is the date of the incident?*

MonthDayYear
Date
Hour MinutesAM/PM Option
Identified staff member(s) involved (if known):*

0/255
Briefly describe the incident or concerns: *

0/255
What challenges made it difficult to resolve this incident?*

0/255
What resolution would be best for you in this scenario?*

0/255
Consent and Acknowledgement

By signing below, I acknowledge:
- Staff may review necessary health records to investigate this grievance.
- All information will be kept confidential.
- Filing this grievance will not affect my care or services at Damien Center.
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:

Patient Grievance Form

Purpose of this form:

Please note:

Other Ways to File a Grievance:

External Reporting Options:

Pharmacy:

Mental Health and Substance Use Treatment:

Civil rights or health privacy violations:

HIV Care:

Consent and Acknowledgement