Complaint, Grievance or Quality of Care Concern

Complaint, Grievance, or Quality of Care Concern

Please complete the following form in its entirety when filing a complaint, grievance or quality of care concern with MIND 24-7. Please note that forms are processed Monday - Friday, 8:00 AM - 4:30 PM. Please allow up to 5 business days for processing.
Your Name:*
Please enter your FIRST and LAST name (or ANONYMOUS if you do not wish to disclose your identity).
Type of Concern:*

ComplaintGrievanceQuality of Care Concern
Nature of the Event: (please select one of the following)*

Patient CarePatient SafetyStaff InteractionQuality of the FoodFacility Issue
Details of the Event: *
Briefly describe the nature of the event.
Where did the event occur:*
Please enter the clinic name or address.
On what date did the event occur?*

MonthDayYear
What is the best way to reach you?*

Call MeEmail MeI wish to remain annonymous.
Phone Number

Area CodePhone Number
Email
example@example.com
Best time to reach you: (select all that apply, or in OTHER enter a specific time/time range)

MorningsAfternoonsEveningsOther
Would you like us to send you an update on the outcome of the investigation?
How would you like to receive an update

PhoneEmailMail (please provide below)
Mailing Address
Upload Files:

Please upload any files to support your claim here.
Cancelof
Thank you for filing your complaint or grievance with MIND 24-7. The satisfaction and safety of our customers is very important to us. We If we have any questions about your submission, we will reach out to the contact information provided above. If you have any questions, please contact us by calling 1-844-MIND247 or by emailing us at complaints@mind24-7.com.
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