Kimball Health Services : Kimball Health Services Patient Complaint Form

Kimball Health Services Patient Complaint Form

KIMBALL HEALTH SERVICES is committed to respecting your right to privacy of your personal health information and in providing quality healthcare. We take all complaints very seriously, and will not retaliate for filing a complaint. To file a complaint, complete this form.
	Complaint Submitted By:	Patient Other
	Patient Name
	Date of Incident (mm/dd/yyyy)
	Address
	City
	State
	Zip Code
	Nature of Complaint	HIPAA Violation Quality of Care Billing Customer Service
	Complaint Involves	Clinic Nursing Radiology Lab Rehab Outpatient Services Social Services Administration Health Information ED Provider
	Description of Complaint