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Home / Making a complaint / Complain about care you received

Complain about care you received

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This complaint form gathers the information we need to review your complaint.

BEFORE YOU COMPLETE THIS COMPLAINT FORM
Before filling in the form, you may wish to talk to the person or organisation you’re unhappy with. An advocate can help you to try to resolve your complaint directly with the healthcare provider, instead of making a complaint to HDC.

When you make a complaint to HDC, we will assess your complaint and guide you to resolve it. Please know that if you make a complaint, we will discuss it with the person or organisation you are complaining about.

If you have any questions about this form, contact us at:

Email: hdc@hdc.org.nz
Phone: 0800 11 22 33
Mail: PO Box 1791, Auckland 1140, New Zealand

THE INFORMATION WE COLLECT FROM YOU
We collect personal information from you, including your contact information, health information, and demographic details such as your age group and ethnicity. We may also collect information from other people and organisations about your complaint, including related clinical records.

We collect this information to:
• help HDC to assess and resolve your complaint;
• promote and protect the rights of people using health and disability services;
• monitor, report on and improve the quality of our complaints process.

When a complaint is made about a person or organisation, they must be given a fair opportunity to consider the complaint and respond. Normally we send the information in your complaint to the relevant people for their response.

WE PROTECT YOUR PRIVACY
You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong.

We may provide information we receive from you, and from your health or disability services provider, to a health and disability advocate. Often we ask advocates to talk through resolution options or to help with clarifying or resolving complaint issues.

Sometimes HDC creates case studies for publications and presentations. We may use a complaint you are involved in for a case study. If we do, we remove names and places.

THE INFORMATION WE COLLECT AND THE PRIVACY ACT
When we collect, use, and share personal information we comply with the Privacy Act and the Health Information Privacy Code. This includes personal health information.

Step 1 - About You

Title*

Please select a title from the drop-down list

Other

If you've selected 'Other', please specify

First Name*

Please enter your first name(s)

Last Name*

Last Name is required

Your address*

Please enter your address

Date of birth

NHI

Stands for National Health Index. The NHI number is a unique identifier assigned to every person who uses health and disability support services in New Zealand. If you know your NHI number, enter it in this field.

Home Phone

Business Phone

Mobile Phone

Email address

Post

Specify your preferred method of contact:

Tell us which method of contact you would prefer

Phone Call

Post

Please specify the preferred method of contact

Step 2 - Your Complaint

Name of the person and/or organisation who provided the service

A service provider needs to be entered here

Type of health or disability service provider

Please select one or more from the list by using the 'CTRL' key and clicking with your mouse.

Please select at least one provider type

Other provider (please specify)

Address (location where service provided)

Provider address needs to be entered here

Phone Number (if known)

What is your relationship to this person/organisation?

Please select one or more from the list by using the 'CTRL' key and clicking with your mouse

Please specify the relationship between you and your provider

Other relationship - please specify

Step 3 - What Happened

Tell us what you want to complain about. Be clear, and focus on the main problem(s).

Describe the events you want to complain about.

We need to know:
- what happened;
- who it happened to;
- when it happened (the date and time);
- where it happened; and
- who did it (person or organisation).

You can attach files, such as photos and documents, here. Each file will need to be attached separately.

Attach 1st file here:

Attach 2nd file here:

Attach 3rd file here:

Please give us all the dates and relevant details that you can remember.

This is a required field.

If the events you are complaining about occurred more than two years ago, please tell us the reasons for the delay around this complaint.

Step 4 - Tell us more about your complaint

Witnesses: Are there other people who can help us with any questions we may have? Please tell us their names and how to contact them. For each one, explain how they may be able to help.

If there are witnesses who could assist in providing some information, please enter the details here.

Results: What do you want to achieve by making this complaint? Be clear about what you want to see happen.

Other ways to resolve a complaint: Have you tried to resolve your complaint in another way - for example, by meeting with the person or organisation you are unhappy with, or working with an advocate? If so, please give details, including the outcome. Please provide copies of any emails or letters between you and the person or organisation, or notes from meetings. You can email them (hdc@hdc.org.nz), attach them to this form (see above), or post them to us with a cover letter.

Other Agency/Agencies: Have you made a complaint to another agency about this matter (for example, ACC, the Human Rights Commission, the Privacy Commissioner, the Police)?

Yes

Please select one option

If Yes, please give details, including the outcome.

Special communication needs: If you have special communication needs, please let us know here. For example: "I prefer documents in large print"; "Please talk loudly and clearly as I have a hearing impairment”.

5. Demographics

This information is collected to help us improve our complaints process and will be kept confidential. If you do not want to provide this information it will make no difference to how we handle your complaint.

Age Group

Under 15

15 to 17 years

18 to 24 years

25 to 34 years

35 to 49 years

50 to 64 years

65+

I do not wish to answer

Gender:

Male

Female

Another gender (Please specify below)

I do not wish to answer

Please specify gender

Another gender

Which ethnic group do you belong to? Mark the ethnicities which apply to you

Please specify which ethnicity group you belong to. Multiple options can be selected by pressing and holding the 'CTRL' key on your keyboard and selecting the ones you want.

You need to specify at least one option

Other such as DUTCH, JAPANESE, TOKELAUAN. Please state:

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