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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.
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.
Fill out this section only if you are complaining on behalf of someone else, ie, the person who received the health or disability service.
The Privacy Act and Health Information Privacy Code state that we may only release personal information (including personal health information) to people who are entitled to that information. Therefore, if you are not the consumer of the services being complained about, please advise whether you are one of the following:
If you are not one of the people outlined above, is the Consumer aware you are making a complaint on their behalf?
If they are aware, please ask the Consumer to confirm, in writing or by email, that they support the complaint and whether they agree to the release of their personal information (including personal health information) to you.
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