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Online Complaint Form

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Step 1. About You

This form is designed to help you make a complaint to the Health and Disability Commissioner about the quality of health or disability services provided to you or someone else.

Before filling in the form, you may wish to consider first talking to the provider you are unhappy with. If you would like assistance with this, you can seek the assistance of an Advocate to help you resolve your complaint directly with the provider, instead of going to the Commissioner.

If you decide to use this form, please check that you have answered all the questions marked with an asterisk. The complaint form is specifically designed to gather the information we need to review your complaint.

If you require any assistance to complete this form, please contact one of our Complaints Assessment staff on 0800 11 22 33 or a health and disability advocate on 0800 555 050.

If you have any questions about the collection, use and disclosure of the information collected on this form, please call our helpline on 0800 11 22 33.

Your Details (The complainant)
 
 
 
 

I am making a complaint about a health or disability service received by me.

I am making a complaint on behalf of someone else who received the health or disability service.

 

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