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  • 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
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  • You are welcome to submit this form without contact information, but that means we cannot follow up with you about the issue or solution.

  • 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.

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  • 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.
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