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Goodland Regional Medical Center

Report of Patient & Family Concern

Goodland Regional Medical Center
220 W. 2nd Street - Goodland, KS 67735
Confidential Pursuant to KSA 65-4925
Not Part of the Medical Record
Please complete form and select "Submit" to send a copy to the GRMC Risk Manager.
* Date:
Today's date
* Person Taking Information:
* Patient Name:
  M/R #:
If Available
* Concern Initiated by: Patient     Family Member     Staff Member     Other    
* Address:
Of Patient, Family Member or Other
* Phone Number:
Of Patient, Family Member or Other
* Date of Incident:
* Describe the problem: