Untitled Document

Health Facility Services receives and investigates complaints against Non-Long Term Care Facilities for non-compliance with Medicare Regulations and/or State Licensure Regulations. Complaints may be filed electronically through the Health Facility Services Website Complaint Intake/Form below or via a call, mail, fax or email directed to:

Health Facility Services
Arkansas Department of Health
5800 West Tenth, Suite 400
Little Rock, AR 72204
Phone: 501-661-2201
Fax: 501-661-2165
Email

* Required Fields

First Name:
Last Name:
Email:

*Regarding:


Please answer the following questions along with a narrative of the incident.
Is confidentially desired?	Yes No

What is your address and telephone number?
Address:
City:
State:
Zip:
Phone:	Example: (xxx) xxx-xxxx

What is the name of the person your calling about? How are you related to this person?


What is the name and address of facility/laboratory/practitioner?
Name:
Address:
City:
State:
Zip:

What happened?


Date Problem Occured: mm/dd/yy
Time Problem Occured: hh:mm AM/PM

Is the problem ongoing?


How did it happen?


Is anyone else involved, such as other staff, volunteers, family members, other patients or resident, visitors?


Have you taken any actions? Did you speak to the administration, manager or any staff of the facility/laboratory/practitioner’s office?


Has the facility/laboratory/practitioner tried to address situation?


The following questions do not apply for laboratories, perfusionists and OPPs:
Is the resident/patient still in the facility?


Are there any witnesses?


Are law enforcement agencies involved?


Do you know if this has happened before to the same individual or to others?