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Ombudsman Complaint
Instructions
Ombudsman Instructions
LTC Ombudsman complaints can also be submitted by calling the
LTC Ombudsman Complaint Line at (518)-417-6587.
LTC Ombudsman Contact Information:
Providing information about you will allow Department staff to contact you should additional information be needed. It is our policy to keep your name confidential.
LTC Ombudsman Contact Information
Ombudsman Number
Ombudsman Name
First
?
Last
?
Date
?
Daytime Phone Number
Contact Text
Please provide your contact information for the Department
Local Ombudsman Regional Office Phone Number
Email Address
?
Resident Information
First and Last Name
First
?
Last
?
Current Location of the Resident
Type of facility the resident is/was residing in
?
- Select -
Nursing Home
Adult Care Facility
Date of LTC Facility Discharge, if applicable (MM/DD/YYYY)
?
Facility Information
Facility Name
?
Facility Address
Address
Address 2
City/Town
State
NY
Facility Address
ZIP/Postal Code
Complaint Information
What is the date that your concern occurred? (MM/DD/YYYY)
Description Instructions
Provide a detailed description of the complaint. Include time, date, shift of occurrence, involvement of any staff and/or residents and any witnesses. Please limit your complaint to 1000 words.
Provide a detailed description
Submit
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