Grievance Form-Treatment
Port Recovery IOP, Inc. Grievance Form
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Port Recovery IOP, Inc.


Complaint/Grievance Form

You have the right to file a complaint with us about our privacy practices or our compliance with our Notice of Privacy Practices, or our Privacy Policies and Procedures.  To exercise this right, please complete, sign and date the following form, then submit this complaint to us at:

 

Port Recovery IOP, Inc.

Attn: Executive Director

8615  Ridgely’s Choice Drive Ste 205  Nottingham MD 21236

 

You may in addition or in the alternative to filing a complaint with us, file a complaint with the

United States Department of Health and Human Services.

200 Independence Avenue S.W

Washington, D.C 20201

1-877-696-6775

 


Print Name- Or you can remain Anonymous if you don't want to provide your name.  However we will not be able to respond to you directly in how to resolve your complaint or concern *
Telephone Number *
Email Address
Client Complaint -Please provide detailed description of your complaint.
Please tell us what resolution you are seeking for this complaint.
By selecting the "I Agree" button, you are signing this attendance sheet electronically. You agree your electronic signature is the legal equivalent of your manual signature on this sign in sheet.
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