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This complaint form is designed to gather the information we need in order to review your complaint. Before filling in this form, you may wish to consider talking to the provider you are unhappy with. If you would like assistance with this, an advocate can help you to try to resolve your complaint directly with the provider, instead of making a complaint to the Commissioner.
The Privacy Act and the Health Information Privacy Code state that we may collect, use and disclose personal information (including personal health information) only in ways that are authorised by the Privacy Act. We collect personal information from you, including your contact information and health information.
We may also collect information from other parties regarding your complaint, including (if required) the relevant clinical records. We collect all of this information in order to enable HDC to assess and resolve your complaint, to promote and protect the rights of health consumers and disability service consumers, and for monitoring and statistical purposes.
When a complaint is made about a provider, the provider must be afforded a fair opportunity to consider and respond. It is our usual practice to send the information in your complaint to the relevant provider or providers for their response.
Case studies are sometimes published by HDC and used in presentations. This is a way of protecting and promoting the rights of health consumers and disability service consumers by highlighting cases of specific interest. We may use a complaint you are involved in but will anonymise your identity and that of other parties involved.
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.
Our office will be closed over the Christmas period from 21 December 2018 and reopening on Thursday 3 January 2019. We will respond to your request upon our return. We hope you have a safe and relaxing holidays and a happy New Year.
If you have any questions about any of the above, please contact us at email@example.com, or 0800 11 22 33, or PO Box 1791, Auckland 1140, New Zealand prior to completing the complaint form.
Please select a title from the drop-down list
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.
Other (please specify)
Address (location where service provided)
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
Before filling in this section, take a few moments to identify the issue you want to complain about. Be clear, and keep focused on the main issue(s).
Describe the events you want to complain about. We need to know:
- what happened;
- who it happened to;
- when it happened (the date);
- where it happened; and
- who did it.
If you wish to attach any documentation, you can do so below.
Please give us all the dates and relevant details that you can remember.
If the events you are complaining about occurred more than two years ago, please tell us the reasons for the delay in bringing the matter to our attention.
Step 4 - Tell us more about your complaint
Witnesses: Are there other people who can help us with any enquiries we may make? Please tell us their names and how to contact them, and explain how they may be able to help us.
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?
Other paths to resolution: Have you tried to resolve your complaint in another way - for example, by meeting with the provider you are unhappy with, or working with an advocate? If so, please give details, including the outcome. If you have copies of any correspondence with the provider, or notes from meetings, it would be helpful to supply copies of these to us either by email (firstname.lastname@example.org), post, or by attaching them below.
If Yes, please give details, including the outcome.
Special communication needs: If you have special communication needs we should know about when responding to your complaint, please let us know below (for example: "I prefer documents in large print"; "Please talk loudly and clearly as I have a hearing impairment," etc).
Please specify ethnicity
Do not wish to answer
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