Healthcare Civil Rights Complaint Form
Use this form to report discrimination, denial of services, accessibility barriers, retaliation, or other civil rights concerns in a healthcare setting.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Email
Phone
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Healthcare Facility or Provider Name
*
Location of Incident (City and State)
*
Type of Complaint
*
Discrimination
Unequal Treatment
Denial of Services
Accessibility Barriers
Retaliation
Other
Describe the incident or concern
*
Upload any supporting documents (optional)
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