Hea 1685 Form PDF Details

In the realm of health care and patient rights, the ability to voice concerns and complaints about the care received in healthcare facilities is paramount. The Ohio Department of Health provides a structured way for individuals to report these concerns through the HEA 1685 Complaint Form. This document, issued by the Provider and Consumer Services Unit Division of Quality Assurance, serves as a formal channel for lodging complaints. Individuals have the option to file complaints anonymously, ensuring their privacy is protected, though this option limits the department's ability to follow up directly with the complainant. For those who choose to disclose their identity, the form requests detailed information including the complainant's contact details, specifics about the facility in question, and the resident or patient involved, alongside the description of the alleged issue. Importantly, the form underscores the confidentiality of person-identifiable information, ensuring that complainants' and patients' details are handled with the utmost sensitivity. Additionally, it allows for the inclusion of information about any alleged wrongdoer(s), thereby providing a comprehensive mechanism for reporting and potential subsequent investigation. Through sectioned prompts, the HEA 1685 form guides the complainant in providing a clear and detailed account of their concerns, ensuring that crucial information is conveyed effectively to the Ohio Department of Health for review and action.

QuestionAnswer
Form NameHea 1685 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesohio department of health r302 form, hea1685, ohio department of health complaint, anonymous report to health department

Form Preview Example

PROVIDER AND CONSUMER SERVICES UNIT

DIVISION OF QUALITY ASSURANCE

OHIO DEPARTMENT OF HEALTH

COMPLAINT FORM

You may file this complaint ANONYMOUSLY, by NOT providing us your name and address. Skip to Section II if you wish to remain anonymous. If you remain anonymous, ODH will not be able to contact you to obtain additional information or notify you of the results of the complaint investigation.

Section I Complainant Information – Complete only if you wish to receive our acknowledgement and notification letters with the results of the complaint investigation

Complainant Name:

Street Address:

City:

State:

 

Zip:

 

 

 

 

Primary Telephone:

 

Secondary Telephone:

( )

 

(

)

 

NOTE: All person-identifiable information is confidential.

Section II Facility Information

Facility Name:

Address:

City:

State:

Zip

Telephone:

Section III Resident(s)/Patient(s) Information

 

Resident/Patient Name:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

Relationship to Resident/Patient:

 

Is the Resident/Patient still in the facility?

 

 

 

 

฀ Yes

฀ No

 

 

 

Additional Name(s):

 

 

 

 

 

 

Name:

 

 

Date of Birth:

 

 

 

Relationship to Resident/Patient:

Is the Resident/Patient still in the facility?

฀ Yes

฀ No

 

 

 

 

 

 

 

 

Name:

 

 

Date of Birth:

 

 

 

Relationship to Resident/Patient:

Is the Resident/Patient still in the facility?

฀ Yes

฀ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section IV Alleged Wrongdoer(s) Information – if applicable or known

Name:

Title:

Additional Name(s)/Title:

Name and Title:

Name and Title:

Name and Title:

HEA1685 REV. 4/08

Page 1 of 2

Section V Narrative Description

Provide a narrative description of your complaint which should include date, time and location of the incident. Include name and phone number of any witness(es), if applicable.

HEA1685 REV. 4/08

SUBMIT THIS FORM TO ODH

Page 2 of 2

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hea1685 completion process described (part 1)

2. Just after this selection of blanks is completed, go to type in the relevant information in all these: Section III ResidentsPatients, Is the ResidentPatient still in, Additional Names, Name Date of Birth Relationship to, Name Date of Birth Relationship to, Section IV Alleged Wrongdoers, Title, Name and Title, Name and Title, Name and Title, and HEA Rev.

Name and Title, Section IV Alleged Wrongdoers, and Name Date of Birth Relationship to of hea1685

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hea1685 writing process clarified (part 3)

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