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Phone: (716) 268-8705 Fax: (716) 589-2290

PATIENT COMPLAINT FORM

Complaint reported by: Relationship
Date occurred:
Date reported:
Date due:
Involved Patient name:
Involved employee ID#: Involved patient MR#:
Statement of Complaint:
Investigation:
Findings (is the complaint substantiated or not):
Plan of Correction:
Follow up/Resolution:

Was complaint satisfied with resolution? Yes No
Investigator:


Date:
DPS:


Date:
     

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