Filing a complaint against a DNV Healthcare accredited healthcare organization

If you have a concern regarding the quality of care provided to you or someone else, please consider contacting the healthcare organization first and ask to speak with their "patient advocate." It is the responsibility of a “patient advocate” to address grievances against their organizations.

If you are not able to resolve or diffuse the issue with the organization's patient advocate and want to take further action, please call 866-496-9647, or complete the Patient Complaint Report below.

Complaints/incidents that are not under the DNV Healthcare accreditation jurisdiction may include but are not limited to Medicare/Medicaid fraud, complaints against individual licensed practitioners and how they determine your medical treatment, EMTALA, and billing/insurance issues.

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Healthcare Organization Information

Name of Healthcare Organization

Address

City

State

Zip Code

Specify (if other)

Your Information:

Note: This section is optional. Providing contact information allows DNV - Healthcare to contact you about actions taken in regard to your complaint, or allows us to contact you if more information about your complaint is needed.

Name

Address

City

State

Zip Code

Email

Phone

Do you wish to remain anonymous?

Yes

No

Complaint Information

Disclaimer: The complainant's request to remain anonymous will be honored to the extent permitted by law. The individual receiving the complaint will only reveal the identity of the complainant to those needing to know in order to investigate the complaint.

Date(s) of care related to complaint

Location in healthcare facility related to complaint

Who are you filing complaint on behalf of

Self

Family member

Other (specify)

Specify (if other)

If you are filing on behalf of a patient, are you the healthcare power of attorney or patient's guardian?

Healthcare Power of Attorney

Guardian

NA

Has this complaint been reported to another agency?

Yes

No

Name of agency

Did you receive a response?

Description

Describe the actions that lead to filing a complaint and individuals involved

Desired outcome of complaint

Supporting Documentation

Upload supporting documentation if applicable

Supporting Document 1

Supporting Document 2

Supporting Document 3

Supporting Document 4

Supporting Document 5

DNV Healthcare - Complaint Form

Healthcare Organization Information

Your Information:

Complaint Information

Description

Supporting Documentation