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Health Facility Services – Complaint Form

Complaints

Health Facility Services receives and investigates complaints against Non-Long Term Care Facilities for non-compliance with Medicare Regulations and/or State Licensure Regulations. Complaints may be filed electronically through the Health Facility Services Website Complaint Intake/Form below or via a call, mail, fax or email directed to:

Health Facility Services
Arkansas Department of Health
5800 West Tenth, Suite 400
Little Rock, AR 72204
Phone: (501) 661-2201
Fax: (501) 661-2165
Toll-free: 1-800-223-0340
adh.hfs@arkansas.gov

Complaint Intake/Form

Health Facility Services

Name(Required)
Is Confidentiality Desired?(Required)
Your Address(Required)
Address
MM slash DD slash YYYY
Time Problem Occurred(Required)
:
Is the problem ongoing?(Required)
Have you taken any actions? Did you speak to the administration, manager or any staff of the facility/laboratory/practitioner’s office?(Required)
Has the facility/laboratory/practitioner tried to address situation?
Is the resident/patient still in the facility? (does not apply for laboratories, perfusionists and OPPs)

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