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Denial of Care Submission
Please reach out to the
Japan Civilian Medical Advocacy Facebook Page
if you need any assistance filling out this form.
You may also report injury, trauma, or violation of basic standards to the
Joint Commission by visiting this link.
Want to share your experience about your attempt to medevac?
Please follow the link to fill out this form instead.
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* Indicates required question
Denial of Care
The following questions will ask details about the location and description of your denial.
What is the nature of your submission? (please submit one form per topic)
Choose
Off-base denial
On-base denial
Misdiagnosis and/or Safety event
Date of care request
*
MM
/
DD
/
YYYY
Which base are you affiliated with?
*
Your answer
What is the name(s) of the facility or facilities you attempted to receive care from?
*
Your answer
Please briefly describe the nature of your care request:
*
Your answer
Date of response?
*
MM
/
DD
/
YYYY
Please describe the reason you were denied care from this facility:
*
Your answer
If your denial of care was experienced at an
on-base facility
, please share what challenges you have faced or may face by attempting to receive care from local facilities:
Your answer
If your denial of care was experienced at an
on-base facility
, have you submitted a report to the Joint Commission?
(If you've experienced a violation of standards such as lack of response from the military treatment facility, safety concerns, misdiagnoses, etc, have you reported this to the Joint Commission? An anonymous report can be filed in minutes:
You may do that at this link.
)
Yes
No
Clear selection
Denial of care accounts are entered into an anonymous spreadsheet to inform decision makers of realities for patients in Japan. If you would like to share your name for media interviews or to be contacted for further information, please provide your information below
(Note: identifying information will not be featured on the live denial of care tracker spreadsheet)
*
Yes, anonymously.
Yes, I will provide a name below.
Yes, I will provide a name and email to contact me if you need further information.
Required
Part II: Consent
The next set of questions are for submitters that wish to be named, partially-named or contacted for further information regarding your testimonial.
Your name
Your answer
Your email address
Your answer
Submit
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