Patient Brokering Form
Please fill out the form to the best of your knowledge.  Leave a response blank if you are unsure or uncomfortable.
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FACILITY INFORMATION
Please provide the following information related to the facility.
Facility's Name: *
Facility's Address:
COMPLAINANT INFORMATION
If you wish to be anonymous, please check below.  If you wish to receive releasable information about your complaint, please provide your inform below.
Do you wish for this complaint to be anonymous? 
Anonymous complaints will not receive a direct response and you will not be contacted.
 *
Name (First/MI/Last):
Your Address:
Phone Number:
Email:
Relationship to the patient, resident, or consumer:
AFFECTED PATIENT, RESIDENT, OR CONSUMER INFORMATION
Has the patient, resident, or consumer been directly affected by this? *
Patient Name (First/MI/Last): *
 Patient Age/DOB:
Room #/Floor:
Diagnosis (Reason for receive care from facility):
Physician Name:
Is the patient, resident, or consumer still receiving care or services? *
PRELIMINARY ACTIONS TAKEN
Having you spoken to the administrator, manager, or any staff of the facility about this complaint? *
If yes, what was the result of speaking to the administrator, manager, or any staff of the facility about this complaint?
When did the problem occur? *
MM
/
DD
/
YYYY
What time of day did the problem occur? *
Required
Is the problem ongoing? *
Have you already filed this complaint with OHFLAC at an earlier date? *
Do you know if this problem has happened before to the same individual, or to others? *
Are law enforcement agencies involved? *
Where did the problem occur? *
Who are the witnesses, if any? *
What happened? *
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