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NM Consumer Complaint Form

If you think a health care entity may have violated the law relating to your care, or the care of someone you know, please provide as much detail as possible on the complaint form below. When completing the form, please include as much information as possible. Incomplete information may result in our inability to take action. Please understand that not all concerns may be actual violations of the law. In general, incidents older than twelve months do not result in an on-site investigation, though the information is retained in our file. After we have reviewed your information, we will send you an e-mail response explaining the disposition of your complaint.

You may wish to remain anonymous but if you do not provide the necessary contact information, we will not be able to contact you further regarding the complaint. If you wish to know the results of the investigation, please include your name, address, and contact information on the complaint form under the Complainant Information section below. You may skip this section if you wish to remain completely anonymous, but the SA will not be permitted to provide any follow up on the outcome of the complaint and will not be able to contact you for additional information should that be necessary.

For more information, contact the Health Facility Complaints Hotline at 1-800-752-8649 or email Incident.Management@hca.nm.gov

Consumer Complaint Form (HFLC)

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Section 1: Complainant Information

Your Name

First Last

Your Address

Street Address Address Line 2 City ZIP Code

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Preferred Method of Contact

Your Email Address

Your Phone

Best Time to Call You

Relationship to the patient/resident:

Self

Spouse

Child

Parent

Sibling

Friend

Caregiver

Other

If OTHER, please specify:

Are you the Healthcare Power of Attorney for the patient/resident?

Yes

If NO, has the patient/resident authorized you to receive information concerning their care?

Yes

(If YES, please upload documentation of that authorization.)

Max. file size: 512 MB.

Do you wish to remain anonymous?

Yes

Section 2: Healthcare Entity Information

Healthcare Entity Name:

Healthcare Entity Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Healthcare Entity Phone:

Section 3: Patient/Resident Information

Patient/Resident Name:

First Last

Date of Birth:

MM slash DD slash YYYY

Age:

Sex:

Date of admission to the healthcare entity (if known):

MM slash DD slash YYYY

Is the patient/resident still receiving services from the healthcare entity?

Yes

I don't know

Floor #:

Room #:

If NO, date of discharge from the entity (if known):

MM slash DD slash YYYY

Discharged to:

Home

Hospital

Different Facility

Deceased

Other (please specify below)

If OTHER, please specify

Is the resident able to answer questions if contacted by our staff?

Yes

I don't know

If YES, please provide the best way to contact the resident:

Section 4: Details of the Complaint

What are your concerns? Please select all that apply:

Care not being provided

Inadequate care

Cleanliness of the facility

Unsafe conditions

Quality of the food

Abuse

Neglect

Exploitation

Roomate conflicts

Room temperature

Lost/stolen items

Noise level

Untrained staff

Poor service from staff

Insufficient staff

Lack of activities/social stimulation

Lack of observation

Inappropriate release of confidential information

Please provide a narrative of the details of the concern(s) selected above and be as specific as possible. If necessary, additional information and/or supporting documentation may be attached to this form below.

Additional documentation

Drop files here or

Max. file size: 512 MB.

You may upload multiple additional files, including documents, images, and audio/video files (maximum file size 512MB).

Where did this occur? Please select all that apply:

Resident/patient room

Dayroom

Bathroom

Dining hall

Entrance/exit to building

Hallway

Stairwell

Kitchen

Patio

Facility grounds

Other

If OTHER, please describe where:

When did this occur? Please provide date(s)/time(s) (if known):

Has this concern occurred before?

Yes

If so, when:

Who was involved? Please include individuals directly involved and those that witnessed the incident/concern. (Check all that apply):

Staff

Resident(s)

Visitor(s)

Family

Other

Please list their first and last name, contact information, and their relation to the resident (if known):

Section 5: Additional Complaint Information

Were your concerns reported to the facility?

Yes

If so, who was it reported to?

When was this reported?

MM slash DD slash YYYY

What was the facility's response?

Were your concerns addressed by the facility staff?

Yes

If YES, what did the facility staff do to address your concerns?

If NO, describe how the facility staff did not address your concerns. Please include a description of the expected resolution.

Did you report your concerns to Law Enforcement?

Yes

If yes, who was it reported to?

When was it reported?

MM slash DD slash YYYY

Please provide the case number (if known):

What was their response?

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