Complain on behalf of someone else

Successful submission

Thank you for submitting this complaint. The HDC team will review and follow-up with you within two to three working days.

Regards

This complaint form gathers information we need to review your complaint about care someone else received.

BEFORE YOU COMPLETE THIS COMPLAINT FORM
Before filling in the form, you may wish to consider talking to the person or organisation you’re unhappy with. When you fill out this form, we assess your complaint and guide you to resolve it.

If you make a complaint on behalf of somebody else, we will discuss your complaint with that person or their representative (for example, their estate executor). We will also 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 about the person who received the services you are complaining about. This includes health details, contact details, and demographic information like their age group and ethnicity.

We also collect personal information about you as the complainant, including contact information. We may also collect information from other people or organisations, including related clinical records for the person who received the services.

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 you complain on behalf of someone else, usually we will contact that person or the person’s representative. We will discuss collecting, using and sharing the person’s personal and health information. We will also ask for their views on the complaint.

When a complaint is made about a person or organisation, they must have a fair opportunity to think about it and reply. Usually we send the information in your complaint to the relevant people for their response.

WE PROTECT PRIVACY
The person you are complaining for has the right to ask for a copy of any personal information we hold about them, and to ask for it to be corrected if they think it is wrong. You also have the right to ask for 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 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 and uses them in publications and presentations. We may use a complaint that involves the person who received the services you are complaining about. 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

Please select a title from the drop-down list
Please enter your first name(s)
Please enter your last name
Please enter your address
Specify the preferred method of contact:
One method of contact is required

About the person you are complaining on behalf of

You need to select one option
Is the person who received the service aware that you are making a complaint on his/her behalf?
Please select one of the options available

We may ask for proof of your relationship with this person. If you have documents that would help with this, please upload them here.

If aware of this complaint, please ask the person to confirm that he/she supports the complaint and agrees to the release of his/her personal information (including personal health information) to you.

Step 2 - Your Complaint

A service provider needs to be entered here
Please enter the provider's address
Please select one or more options.
Please select one or more options

I am complaining about:

Please note that, unless you ask us not to, we will send a copy of your complaint to the service provider about whom you are complaining, as well as to any other providers who may be able to assist in our assessment of your complaint.

If you are complaining about more than one person or organisation, please give us similar information about the other provider(s) in the space below. If you do not know the name of the person, please describe as best as you can the person's position or the job he or she performed, and the time of the incident (eg, evening/morning shift).

Is the person you are complaining for still receiving services from the provider(s)?

Step 3 - What Happened

Tell us about the concerns 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).

If you wish to attach any documentation, you can do so here.

Please tell us what happened

Step 4 - Tell us more about your complaint

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)?
Please select one option

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. Because your complaint is on behalf of someone else we’re interested in these details for both of you.

Your demographics

Age Group
Please select your age group.
Gender:
Please specify your gender.
Select at least one option

Their demographics

Their age group
Please select the age group of the person who received the service.
Their gender
Please specify the gender of the person who received the service.
Please specify gender.
Select at least one option

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