Nursing Home Complaint Form

Instructions

The New York State Department of Health, Division of Nursing Home and ICF/IID Surveillance is responsible for investigating complaints about resident abuse, neglect, mistreatment and incidents occurring in nursing homes in New York State that are related to a State and/or Federal regulatory violation.

Anyone can file a complaint against a Nursing Home. All complaints are confidential and can be made anonymously. Due to HIPPA regulations, the department is restricted from releasing patient protected information regarding a complaint case. It is advisable to have one designated representative when filing a complaint on behalf of the family or a group of individuals since only the person who files the complaint will receive correspondences from the Nursing Home Complaint Program.

You may submit this form multiple ways:

Complaints will be accepted if the occurrence is within the past year of the submission of your complaint to the NYS Department of Health.

In order to process your complaint in a timely manner, please:

  • Type or Print clearly
  • Complete form in its entirety, including your contact information
  • Include any names and phone numbers with whom you have already filed a complaint with.
  • Attach copies of paper materials that support your concern (No originals please)

All complaints received about nursing homes are reviewed by the Department through the Centralized Complaint Intake Unit and appropriate action is taken. If you choose to provide your contact information, the Centralized Complaint Intake Unit will send you a letter which will acknowledge receipt of your complaint and provide information regarding how your complaint will be handled.

Should you have questions, please contact the Centralized Complaint Intake Program at 1-888-201-4563, Monday through Friday 8:30am - 4:45pm, excluding holidays.

*** This form is for Nursing Home complaints only. Complaints about Adult homes and Assisted Living facilities can be reported to the intake program at: 1 866 893 6772 ***

 

Nursing Home Complaint Form

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. It may be necessary to share the nature of your complaint or the resident's name or your name with the facility.
Please provide your contact information for the Department
Do you wish to remain anonymous? (See above explanation)
Resident Information
Current Location
Facility Information
Complaint Information
Is law enforcement involved?
Have you filed a complaint with the facility?
Was your concern resolved?

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.

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