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For Ombudsman Only
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Complaint form
You may use this form to submit a complaint to our office. The complaint will be forward to a Regional Ombudsman, who will be in contact with you if they need more information.
All information received is Confidential. Your name will not be released without your permission.
Information about the resident
First name
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Last name
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Facility Name
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City
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State
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Your relationship to the resident
Self
Spouse
Child
Sibling
Other Relative
Friends
Other
Information about complainant, if different from resident
First
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Last
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Daytime Phone Number (including area code)
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Alternate Phone (home/cell)
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Email Address
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Does the resident know you are contacting the Ombudsman office for assistance?
Yes
No
Please describe the nature of your concern or complaint.
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