Hospital Patient Advocate Complaint - Patient Rights Grievance

Instructions for Use

This template is for filing a formal grievance with a hospital's patient advocate or patient relations department regarding violations of patient rights. Under CMS Conditions of Participation (42 CFR 482.13), hospitals must:

• Protect and promote patient rights
• Have a grievance process approved by the governing body
• Investigate and resolve grievances promptly
• Provide written response to grievances

A "grievance" under CMS regulations includes complaints about:
- Patient care quality
- Abuse or neglect
- Hospital compliance with CMS Conditions of Participation
- Medicare billing issues related to patient rights

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Patient Grievance Form

[Date]

VIA CERTIFIED MAIL AND HAND DELIVERY

[Hospital Name]
Patient Advocate / Patient Relations Department
[Street Address]
[City, State, ZIP]

FORMAL PATIENT GRIEVANCE

Re: Formal Complaint Regarding Patient Rights

Field	Information
Patient Name	______________________________________________
Date of Birth	______________________________________________
Medical Record Number	______________________________________________
Date(s) of Service/Admission	______________________________________________
Unit/Department	______________________________________________
Account Number	______________________________________________

Dear Patient Advocate:

I am filing this formal grievance pursuant to my rights under 42 CFR 482.13 and [State] patient rights laws. I request a thorough investigation and written response addressing each concern raised below.

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Section 1: Patient Information

Field	Information
Patient Full Name	______________________________________________
Date of Birth	______________________________________________
Address	______________________________________________
City, State, ZIP	______________________________________________
Telephone	______________________________________________
Email	______________________________________________
Medical Record Number	______________________________________________

Admission/Visit Information

Field	Information
Type of Visit	☐ Inpatient ☐ Outpatient ☐ Emergency ☐ Observation
Date of Admission	______________________________________________
Date of Discharge	______________________________________________
Admitting Diagnosis	______________________________________________
Unit/Floor	______________________________________________
Attending Physician	______________________________________________
Primary Nurse(s)	______________________________________________

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Section 2: Person Filing Grievance

☐ Patient is filing on own behalf

☐ Another person is filing on patient's behalf:

Field	Information
Name of Person Filing	______________________________________________
Relationship to Patient	______________________________________________
Address	______________________________________________
Telephone	______________________________________________
Email	______________________________________________

Authority to File:
☐ Healthcare Power of Attorney
☐ Legal Guardian
☐ Next of Kin
☐ Personal Representative under HIPAA
☐ Patient's written authorization (attached)
☐ Other: ______________________________________________

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Section 3: Nature of Grievance

Category of Complaint (Check all that apply)

Quality of Care:
☐ Inadequate medical treatment
☐ Medication errors
☐ Delayed treatment
☐ Misdiagnosis
☐ Surgical/procedure complications
☐ Failure to follow treatment plan
☐ Inadequate monitoring
☐ Failure to respond to patient needs
☐ Premature discharge

Patient Rights Violations:
☐ Lack of informed consent
☐ Violation of privacy/confidentiality
☐ Denial of access to medical records
☐ Not informed of rights
☐ Restraint/seclusion issues
☐ Advance directive not followed
☐ Denied visitation rights
☐ Not involved in care decisions
☐ Cultural/religious needs ignored
☐ Language/interpreter issues

Safety Concerns:
☐ Fall
☐ Hospital-acquired infection
☐ Equipment malfunction
☐ Unsafe environment
☐ Medication safety issue
☐ Wrong site/wrong patient procedure

Staff Conduct:
☐ Rude or disrespectful behavior
☐ Unprofessional conduct
☐ Physical abuse
☐ Verbal abuse
☐ Neglect
☐ Discrimination
☐ Sexual harassment/misconduct

Billing and Financial:
☐ Billing errors
☐ Not informed of financial responsibility
☐ Insurance not billed properly
☐ Financial assistance not offered
☐ Inappropriate collection practices

Communication:
☐ Not informed of diagnosis/prognosis
☐ Not informed of treatment options
☐ Questions not answered
☐ Discharge instructions inadequate
☐ Family not kept informed (with patient consent)

Other:
☐ Complaint about physical environment
☐ Food/dietary issues
☐ Wait times
☐ Other: ______________________________________________

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Section 4: Detailed Description of Incident(s)

Incident 1

Date: ______________________________________________

Time: ______________________________________________

Location in Hospital: ______________________________________________

Staff Involved (names if known):

_______________________________________________________________________________

Detailed Description (what happened, who was involved, what was said/done):

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Witnesses (names and contact information if known):

_______________________________________________________________________________

Incident 2 (if applicable)

Date: ______________________________________________

Time: ______________________________________________

Location in Hospital: ______________________________________________

Staff Involved:

_______________________________________________________________________________

Detailed Description:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Incident 3 (if applicable)

Date: ______________________________________________

Time: ______________________________________________

Location/Staff:

_______________________________________________________________________________

Description:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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Section 5: Impact of Incident(s)

How were you harmed or affected?

Physical Impact:
☐ Physical injury (describe): ______________________________________________
☐ Worsened medical condition
☐ Additional treatment required
☐ Extended hospital stay
☐ Readmission required
☐ No physical impact

Emotional/Psychological Impact:
☐ Emotional distress
☐ Anxiety
☐ Loss of trust in healthcare system
☐ Fear of returning to hospital
☐ Other: ______________________________________________

Financial Impact:
☐ Additional medical expenses
☐ Lost wages
☐ Out-of-pocket costs
☐ No financial impact

Detailed Impact Statement:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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Section 6: Previous Attempts to Resolve

Did you try to resolve this issue before filing this grievance?

☐ Yes - Describe attempts:

Date	Person Contacted	Their Position	Response
_____	_______________	______________	________
_____	_______________	______________	________

☐ No - Reason: ______________________________________________

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Section 7: Supporting Documentation

Documents Attached (check all that apply)

☐ Medical records (if already obtained)
☐ Discharge summary
☐ Photographs of injury/condition
☐ Written statements from witnesses
☐ Previous correspondence with hospital
☐ Insurance Explanation of Benefits
☐ Billing statements
☐ Advance directive/healthcare power of attorney
☐ Patient handout received at admission
☐ Consent forms signed
☐ Other: ______________________________________________

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Section 8: Requested Resolution

What outcome are you seeking? (Check all that apply)

Investigation and Accountability:
☐ Thorough investigation of incident(s)
☐ Identification of responsible staff
☐ Disciplinary action where appropriate
☐ Changes to prevent recurrence

Communication:
☐ Explanation of what happened
☐ Formal apology
☐ Meeting with hospital administration
☐ Meeting with involved staff (with appropriate supervision)

Medical:
☐ Correction of medical records
☐ Additional medical evaluation
☐ Follow-up care
☐ Transfer of care to different provider

Financial:
☐ Adjustment/reduction of bill
☐ Refund of payments
☐ Financial assistance consideration
☐ No further collection activity during investigation

Policy Changes:
☐ Review and revision of relevant policies
☐ Staff training/education
☐ System improvements

Other:
☐ Written response addressing each concern
☐ Other: ______________________________________________

Detailed Statement of Desired Resolution:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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Section 9: Patient Rights Reference

Federal Patient Rights (42 CFR 482.13)

Under CMS Conditions of Participation, I have the right to:

• Be informed of my rights and hospital rules
• Make informed decisions about my care
• Formulate advance directives
• Have a family member or representative notified of admission
• Personal privacy and confidentiality
• Access my medical records
• Receive care in a safe setting free from abuse
• Be free from restraints not medically necessary
• Be free from seclusion and restraints used for coercion or discipline
• Receive information about unanticipated outcomes

Grievance Process Rights

• The hospital must have a formal grievance process
• The hospital governing body is responsible for effective grievance resolution
• I have the right to file a grievance without fear of retaliation
• I have the right to a timely written response

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Section 10: External Agencies

I understand I may also file complaints with:

☐ State Health Department - For licensing/regulatory issues
- Agency: ______________________________________________
- Website/Phone: ______________________________________________

☐ The Joint Commission (if hospital is accredited)
- Website: www.jointcommission.org/report_a_complaint
- Phone: 1-800-994-6610

☐ CMS/State Survey Agency - For Medicare Conditions of Participation violations
- Website: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/

☐ State Medical Board - For physician conduct issues
- Agency: ______________________________________________

☐ State Nursing Board - For nursing conduct issues
- Agency: ______________________________________________

☐ HHS Office for Civil Rights - For HIPAA/discrimination issues
- Website: https://ocrportal.hhs.gov/

☐ Quality Improvement Organization (QIO) - For Medicare quality of care
- Livanta (BFCC-QIO): 1-888-524-9900

I reserve the right to file complaints with any of these agencies at any time.

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Section 11: Consent and Authorization

Release of Information

I authorize [Hospital Name] to review my medical records as necessary to investigate this grievance. This authorization includes sharing information with relevant staff involved in the investigation and resolution.

☐ I consent to the hospital contacting me by phone at: ______________________________________________

☐ I consent to the hospital contacting me by email at: ______________________________________________

☐ I prefer to receive communications via mail only

Non-Retaliation Statement

I understand that under 42 CFR 482.13, the hospital cannot retaliate against me for filing this grievance. If I experience any retaliation, I will immediately report it to the Patient Advocate and appropriate regulatory agencies.

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Section 12: Signature

I certify that the information provided in this grievance is true and accurate to the best of my knowledge.

Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

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Hospital Use Only

Field	Information
Date Received	______________________________________________
Received By	______________________________________________
Grievance Number	______________________________________________
Date Acknowledged	______________________________________________
Assigned Investigator	______________________________________________
Target Resolution Date	______________________________________________

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Follow-Up Tracking (For Patient Use)

Date	Contact/Event	Summary	Next Steps
_____	____________	_______	___________
_____	____________	_______	___________
_____	____________	_______	___________
_____	____________	_______	___________

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Response Expectations

Under CMS guidelines, hospitals are expected to:

1. Acknowledge receipt of grievance promptly
2. Investigate thoroughly with qualified personnel
3. Respond in writing (average 7 days, varies by complexity)
4. Written response should include:
   - Name of hospital contact person
   - Steps taken for investigation
   - Results of investigation
   - Date of completion

If resolution is delayed, you should receive:
- Written explanation of delay
- Estimated completion date

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Resources

• CMS Patient Rights: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
• The Joint Commission: https://www.jointcommission.org/
• State Health Department: [State-specific link]
• Medicare Quality of Care Complaints: 1-800-MEDICARE

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This template is provided for informational purposes only and does not constitute legal advice. Consult with a healthcare attorney or patient advocacy organization for specific legal guidance.