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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 about the person who received the health or disability services being complained about, including contact information and health information. We also collect personal information about you as the complainant, including contact information. We may also collect information from other parties regarding your complaint, including (if required) the relevant clinical records of the person who received the services being complained about. 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 you complain on behalf of someone else, usually we will contact that person or the person's representative (eg, executor) to discuss collection, use and disclosure of the person's personal and health information and seek his or her views on the complaint.
When a complaint is made about a provider, they 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 that involves the person who received the services you are complaining about, but will anonymise the person’s identity and that of other parties involved.
The person on whose behalf you are complaining has the right to ask for a copy of any personal information we hold about him or her, and to ask for it to be corrected if it is thought to be 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 it is thought to be wrong.
If you have any questions about any of the above, please contact us at firstname.lastname@example.org, or 0800 11 22 33, or PO Box 1791, Auckland 1140, New Zealand.
About the person you are complaining on behalf of
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
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).
Before filling in this section, please take a few moments to identify the issues you want to complain about. Please be clear, and keep focused on the main issues.
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.
Step 4 - Tell us more about your complaint