Complaint Report | HyCare Medical Services

Forms

Complaint Report Form

This form is to assist you in making a complaint to our organisation.
All persons wishing to make a complaint can speak with the Manager or staff member of choice or choose to complete this form.
All information is strictly confidential.
If you feel unsure about anything or would like help to complete this form, please speak to the admin person.
We encourage you to make your complaint in writing. Please allow a maximum of ten (10) days for a response.
Please attach copies (not the original) of any documents that may help us to handle the complaint.
If you still wish to raise this complaint about us to the NDIS commission, please contact 1800 035 544.

Part A: About me

Date

Full name

Address

Phone Number

Is there someone else (legal representative or support person) that you would like involved in making this complaint?

YesNo

Name of legal representative/support person

Fill in this box if you are putting this complaint on behalf of someone else

Name of person

What is your relationship with that person?

Phone number

Does the person know you are making this complaint?

YesNo

Does the person consent to the complaint being made?

YesNo

Part B: Your complaint

What is your complaint about?Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved.

Did someone witness the incident?Would they be willing to be contacted regarding your complaint? If so, provide the name and contact details.Inform the witness that they may be contacted by the organisation to discuss the matter.

Part C: Requirement

How can we help to fix this problem or complaint?

Part D: Reasons and prevention methods

Cause of the incident and preventative actions