Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Ivinson Memorial Hospital

PATIENT COMPLAINT AND GRIEVANCE FORM

This is a complaint and grievance form.
Any staff member can take your grievance. You can file it in any way you want: in writing, by phone (ext. 6685, 0, or 6125), by fax (307-742-0678), or in person. If you are unable to file the grievance yourself, a Discharge Planning/Social Services staff member (ext 2609) will assist you or your representative.
* Name
  Phone
  Address
* Email
* Are you a: Patient
Patient Advocate
Family
Other
* Complaint or Grievance Description
Please give a detailed description of the issue or problem you would like the hospital to address. Include specific names, dates, places, or other details that will help us look into your concerns.
  Desired Out
Describe what outcome(s) you would like to see as a result of this process.