Grievance Form

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Grievance Form

This form is to be used to file a complaint or grievance against Advocacy Links staff or a provider. This information will be treated as confidential and identifying information will only be disclosed when absolutely necessary. If you require assistance to complete the grievance form, please call 1-888-537-5733 ext. 19 for the Advocacy Links Compliance Officer who investigates grievances. You may also file complaints with the Bureau of Quality Improvement - 800-545-7763. Allegations of Abuse or neglect can be reported to Adult Protective Services - 800-992-6978 or for children, Department of Children's Services - 800-800-5556

Whom is grievance being filed against? Please include name, company and title if appropriate

Date of Grievance

YYYY

Name of person filing grievance. If grievance is against Advocacy Links staff, please note your relationship to the Advocacy Links staff

Phone number of person filing grievance

Email address of person filing grievance

Please provide detailed information about the grievance including nature, date and cause.

Findings and decisions will be shared upon completion of all investigations. Please indicate below how you would like to receive results:

Phone call

Postal Mail

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Please provide contact information as requested above so that you receive results.

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