Health and Counseling Services Complaint/Grievance Form Copy

Health and Counseling Services Complaint Form

This form may be used to file a compliant with the Executive Director of the Eastern Illinois University Health and Counseling Services regarding care, treatment, and services received through the HCS Medical Clinic, Counseling Clinic, Student Insurance Program, or Health Education Resource Center.

A complaint may also be filed without using this form by submitting a detailed written letter or e-mail to the Executive Director summarizing your complaint.

If you choose to use this Complaint Form, please complete the following information. Please state all facts which you believe justify your complaint.
Name of Patient Name of Patient First Last
E#
EIU Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Preferred Phone Number Preferred Phone Number - ### - ### ####
Preferred Texting Number (if different from phone) Preferred Texting Number (if different from phone) - ### - ### ####
Complaint Against

Complaint Against Medical Provider (Physician, Doctor, Nurse Practitioner) Counselor/Therapist Nurse Allied Health (Lab, X-Ray, EKG, Pharmacy) Front Desk - Medical Clinic Front Desk - Counseling Clinic Health Education/Promotion/HERC Student Insurance
Individuals Complaint Is/Are Against
Date(s) in which event(s) being reported are taking place?
Has patient/complainant contacted the provider/staff member directly about the complaint?

Has patient/complainant contacted the provider/staff member directly about the complaint? Yes No
If yes, what actions were offered or taken by the provider/staff member?
Please describe your complaint in detail, indicating what occurred, when it occured, all parties involved, witnesses present, etc.
Solutions or actions you wish that Health and Counseling Services take to correct this situation.
Name of Complainant (if not student involved in the incident) Name of Complainant (if not student involved in the incident) First Last