HHS - Assisted Living Facility Complaint Intake

ASSISTED LIVING FACILITY COMPLAINT INTAKE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
SFN 62498 (4-2024)

Date

Hour MinutesAM/PM Option

Name of Person Submitting Form (First, Last)*

Phone Number*

Address

City

State

ZIP Code

Email Address

Name of Resident/Patient

Relationship to Resident/Patient

Name of Facility*

Type of Facility*

Assisted LivingBasic CareOther/Unknown

Location of Facility*

Describe Complaint or Concern (give as much detail as possible including names, dates and times)*

Describe Action Taken Regarding this Complaint or Concern (if any)