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Complainant Information

Insurance Information

Provider Information

Complaint Details and Summary

Previous Contact:

Witnesses or Other Contacts:

Complaint Summary:

Consent to ACHC Investigation

ACHC's Accreditation Standards define procedures for the delivery of health care services. Our Accreditation Standards incorporate standards from state and federal laws and the health care industry. After receiving your Complaint, ACHC will conduct an initial review and assessment to determine if your Complaint involves a potential violation of the ACHC Accreditation Standards. After this initial review and assessment, ACHC will inform you whether we have decided to start an investigation, and we also will inform you of the result of our consideration of your Complaint.

Other than disclosures to government agencies, ACHC will not disclose the names of Complainants, Patients, or Witnesses unless permission is given in this form below. However, Provider Organization’s detailed investigation and corrective actions regarding your complaint may provide clues as to these identities. Therefore, while we honor all requests not to divulge particular names, ACHC cannot guarantee anyone's anonymity.

You acknowledge that all the information provided is true to the best of your knowledge and that ACHC has your express permission to disclose your identity. Does ACHC have your permission to disclose your identity as Complainant and also to disclose the identity of each Patient and Witness that you have identified on this form?

All the information provided in this form is true to the best of your knowledge and that ACHC has your express permission to disclose your identity. ACHC has your permission to disclose your identity as the Complainant. ACHC has your permission to disclose the identity of each Patient and Witness that you have approved in the “Name Release” section, above.

Name Release: