"Complaint Form" - Illinois

Complaint Form is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

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Download "Complaint Form" - Illinois

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Actual Form
p. 1
State of Illinois
Illinois Department of Public Health
Complaint Form
Illinois Department of Public Health
Office of Health Care Regulation
Central Complaint Registry
525 W. Jefferson St., Ground Floor
Springfield, IL 62761-0001
Fax Number: 217-524-8885
Email Address: dph.ccr@illinois.gov
Central Complaint Registry Hotline – 800-252-4343
TTY for the Hearing Impaired Only – 800-547-0466
Available 24 hours a day - 7 days per week
Directions: You may download this form, complete the information, and mail, fax, or email it to the Illinois Department
of Public Health’s Central Complaint Registry at the address/numbers provided above. You may also complete the form
and click the submit button for the form to be automatically sent to the Central Complaint Registry email inbox. Please
be sure to fill out the form completely so a proper investigation may be completed.
Complaints submitted on this form are limited to occurrences in hospitals, home health agencies, hospices, end-stage
renal dialysis units, ambulatory surgical treatment centers, rural health clinics, critical access hospitals, free standing
Emergency Center, clinical laboratories (CLIA), outpatient physical therapy, alternative healthcare delivery, portable X-
ray services, community mental health centers, accredited mental health centers (only Medicare Certified),
comprehensive outpatient rehabilitation facilities, health maintenance organizations (HMOs), nursing homes, skilled
nursing homes, licensed facilities for individuals with intellectual disability, and assisted living facilities. The
Department’s Central Complaint Registry is limited to mandates provided in the licensing acts, regulations, and federal
Medicare Conditions of Participation or coverage for the programs the Department manages.
Emails, facsimiles, and mailed complaint forms that are sent/received after 4:30p.m. will not be seen until
next business day. If a resident’s immediate health and/or safety are at risk please call 800-252-4343 to
speak with an IDPH representative.
Date of Occurrence ________________________
Facility___________________________________________________________________________________
Address___________________________________ City_________________ State____ Zip Code___________
Actual Form
p. 1
State of Illinois
Illinois Department of Public Health
Complaint Form
Illinois Department of Public Health
Office of Health Care Regulation
Central Complaint Registry
525 W. Jefferson St., Ground Floor
Springfield, IL 62761-0001
Fax Number: 217-524-8885
Email Address: dph.ccr@illinois.gov
Central Complaint Registry Hotline – 800-252-4343
TTY for the Hearing Impaired Only – 800-547-0466
Available 24 hours a day - 7 days per week
Directions: You may download this form, complete the information, and mail, fax, or email it to the Illinois Department
of Public Health’s Central Complaint Registry at the address/numbers provided above. You may also complete the form
and click the submit button for the form to be automatically sent to the Central Complaint Registry email inbox. Please
be sure to fill out the form completely so a proper investigation may be completed.
Complaints submitted on this form are limited to occurrences in hospitals, home health agencies, hospices, end-stage
renal dialysis units, ambulatory surgical treatment centers, rural health clinics, critical access hospitals, free standing
Emergency Center, clinical laboratories (CLIA), outpatient physical therapy, alternative healthcare delivery, portable X-
ray services, community mental health centers, accredited mental health centers (only Medicare Certified),
comprehensive outpatient rehabilitation facilities, health maintenance organizations (HMOs), nursing homes, skilled
nursing homes, licensed facilities for individuals with intellectual disability, and assisted living facilities. The
Department’s Central Complaint Registry is limited to mandates provided in the licensing acts, regulations, and federal
Medicare Conditions of Participation or coverage for the programs the Department manages.
Emails, facsimiles, and mailed complaint forms that are sent/received after 4:30p.m. will not be seen until
next business day. If a resident’s immediate health and/or safety are at risk please call 800-252-4343 to
speak with an IDPH representative.
Date of Occurrence ________________________
Facility___________________________________________________________________________________
Address___________________________________ City_________________ State____ Zip Code___________
p. 2
All complaints are handled as quickly as possible based upon severity guidelines and priority standards. If an
address is provided, a written response will be sent upon conclusion of the investigation. If an address is not
provided, the complaint will be filed as anonymous and a response will not be available. Please allow up to
120 days to receive the response.
Complainant Name _________________________________________
Address___________________________________ City_________________ State____ Zip Code___________
Daytime Telephone _______________________Cell ______________________
Name of Patient/Resident __________________________________________
Date of Birth____________________ Sex ____________
Current Status of Patient (Transferred, Expired, Hospitalized, still in the facility, discharged, if other please
explain)
__________________________________________________________________________________________
__________________________________________________________________________________________
Identify any witnesses to the occurrence by name and title (Mother, Sister, Brother, friend, RN, LPN, CNA, etc.)
_________________________________
_____________________________________
_________________________________
_____________________________________
Describe what actually occurred. Limit comments to the facts. Identify who, what, when, and where. Describe
any physical harm incurred by the patient.
p. 3
If known, please include if the facility is aware of the situation. Was law enforcement notified? If you
reported the incident identify who you reported the incident/complaint to, the date, and any action(s) taken
by the facility/law enforcement to assist you.
Add description of what occurred here:
Please click on the submit button for the complaint to automatically be sent to the Central Complaint
Registry email inbox. Please print or save this form for your records. Only fax or mail the form if it is not
being submitted via email.
Note: After hitting the submit email button select the “Default email application” in the box
Submit by Email
p. 4
State of Illinois
Illinois Department of Public Health
Illinois Department of Public Health
Office of Health Care Regulation
Division of Health Care Facilities and Programs
Bureau of Long Term Care
Complaint Investigations
Frequently Asked Questions
The Department investigates quality of care issues, such as allegations of actual or potential harm to patients,
patient rights, infection control, and medication errors. The Department also investigates allegations of harm
or potential harm due to an unsafe environment.
Q. What information is needed to file a complaint? Who, what, when, and where.
Who? Patient/resident’s name? Names and titles of any others involved including witnesses?
What? Explain what occurred or did not occur.
When? Date/time of incident.
Where did this occur? Name, address, and City of the facility. Where in the facility did the incident
occur (room number, unit, or department)?
Q. Who may file a complaint?
Complaints may be filed by, but are not limited to, patients, patient family members, care givers, staff or
advocacy groups.
Q. Is the identity of the complainant disclosed?
The identity of the complainant is kept completely confidential. The complainant must provide their
name, address and phone number to the Department if the complainant would like to receive written
notification of receipt of the complaint and notification of the outcome of the complaint investigation.
Complaints may be filed anonymously but the complainant will be unable to obtain the outcome.
Q. What happens after a complaint is filed? When will my complaint be investigated?
Complaints are investigated on a priority basis. Depending on the nature, scope, and severity of the
complaint the investigation may take from a few weeks up to several months for the entire process to
be completed.
p. 5
For providers that are accredited by an accrediting organization such as the Joint Commission; Federal
law authorizes us to investigate a complaint against an accredited facility only if the complaint alleges
the existence of a specific condition(s) that may result in a finding of a substantive health and safety
deficiency under federal requirements. Your allegation will be reviewed and if the information
submitted, does not establish the potential for a significant health or safety deficiency under federal
requirements we cannot request an authorization from the Centers for Medicare and Medicaid (CMS)
for an investigation. The complaint must be so serious that, if substantiated, CMS would take action to
remove the provider from the Medicare program and stop all Medicare payments. We do not have the
authority to impose lesser penalties on providers.
Therefore, in addition to contacting IDPH you may want to contact the accrediting organization for the
assistance in investigating your complaint. The attached link lists all of the various types of Accrediting
Organizations for the various providers:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Accrediting-Organization-Complaint-Contacts.pdf
Q. How do I file a complaint with the Department?
You may file a complaint by telephone, mail, email, or fax. By telephone, you may call the Department’s
Central Complaint Registry, 24 hours a day/7 days a week at 800-252-4343. You may also submit your
complaint in writing to:
Illinois Department of Public Health
Office of Health Care Regulation
Central Complaint Registry
525 W. Jefferson St., Ground Floor
Springfield, IL 62761-0001
Email:
dph.ccr@illinois.gov
Fax: 217-524-8885
TTY: 800-547-0466
If you have Internet access, you may download the complaint form from the Department’s website at
http://www.idph.state.il.us
Q. Are there other agencies that may address some issues or areas of concern?
Yes. Please see the following list for other agencies that may be better able to address your complaint.
For instance, complaints against specific physicians or other licensed health care personnel should be
addressed to the Illinois Department of Professional Regulation. For complaints concerning billing issues
or insurance disputes, please contact either the Attorney General’s Health Care Fraud Unit or the Illinois
Department of Insurance.