Patient Complaint and Grievance

We value your thoughts and experience, whether you have a comment, suggestion or complaint we want to hear from you. Help us improve our care by sharing your feedback. We want to know if you are not satisfied with your care or if you feel like you have been denied any of your Patient Rights and Responsibilities.

You may submit this complaint and grievance ANONYMOUSLY, by not providing us with your name and address. If you remain anonymous,
Ashland Health Center will not be able to contact you to obtain additional information or notify you of the results of your concern or complaint.

Date of Occurrence:*

Date of Birth:

Sex:
MaleFemale

Status of Patient:*
DischargeStill in Facility

Expired:
YesNo

Complainant Full Name (if not the patient):

Briefly describe what actually occurred. Limit comments to the facts. Identify dates, names, places, times, facility, and location(s)
(essentially, who was involved, what happened, when did it occur, where did it occur, and how did it occur).
Describe any physical harm incurred by the patient. Use the form fields to complete the information.*

I hereby declare that the above made statements are true to the best of my knowledge and belief.

You can download the form and drop in the complaint lock box at the Acute or SLU nurses Station or with the Hospital/Clinic Receptionist or mail it to:

Ashland Health Center | Nursing Department
625 Kentucky St, Ashland, KS 67831
Fax: (620) 635-2229

Patient Complaint and Grievance Form download