Skip Navigation

 

 

 

Print this page

 

 

 

Ombudsman Complaint Form

Please complete this confidential form to request assistance in advocating for yourself or your loved one living who resides in a nursing home or assisted living home. We understand that you may not have access to all the information requested, but please be complete as much as possible. An Ombudsman will contact you if you provide your contact information. You may also file a complaint with the facility's licensing agency, Office of Health Care Quality.
Ombudsman Complaint Form
/sebin/b/v/eaead9_Box.jpg
Relationship to Resident:
/sebin/b/v/eaead9_Box.jpg
/sebin/b/v/eaead9_Box.jpg
Do we have permission to reveal your identity during our complaint investigation?
/sebin/b/v/eaead9_Box.jpg
/sebin/b/v/eaead9_Box.jpg
Is the resident capable of making decisions?
/sebin/b/v/eaead9_Box.jpg
/sebin/b/v/eaead9_Box.jpg
Complaint Summary: Note: Include dates, times, persons involved, witness and a description of the incident(s). If reporting anonymously, be complete since we will not be able to obtain more information from you.
Have you notified the facility staff with this complaint?

 

 

Social Networking Icons (Fb, Twitter, RSS, Pinterest, Email List)

 
Anne Arundel County, Maryland. 44 Calvert Street, Annapolis, Maryland 21401 | Tele: (410) 222-7000