WACC Concerns and Grievance Form

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Concerns and Grievance Form

Our team actively works to provide the most efficient and optimal experience for providers and patients. We develop comprehensive policies and procedures to support this effort. However, there may be times provider or patient experiences are less than optimal. When this happens, we encourage the affected individual to openly communicate their concern and collaborate to create an satisfactory outcome. When this cannot be achieved, we encourage individuals to use this form to submit a complaint, concern, or grievance. Upon submission, a team member will review relevant information and respond within 14 days.
Please tell us about yourself and your relationship to our program.
Organization Relationship

I am the patientI am the parent of the patientI am an outside providerI am a current staff member or provider for the organizationI am an advocate (external representative with signed ROI on file)Other
Are you filing the complaint for yourself or on behalf of a patient?

For MyselfOn Behalf of a PatientFor Information Only
Your Name

First NameLast Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Please list the names of other individuals involved in this concern, complaint, or grievance?
Are the individuals listed above aware of your concern, grievance, or complaint?

YesNo
Please describe the status of your concern

The concern has been resolvedThe concern is active and ongoingThe concern is to help prevent a more serious issueThe concern is for information onlyThe concern is to help improve the clinic's internal practicesOther
Please provide an approximate date range of the occurence
Please describe what happened
To your knowledge, please describe what action has already been taken to address this concern, complaint, or grievance
In your opinion, what would be helpful in resolving this concern, complaint, or grievance?
Should be Empty: