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Complaint Intake Form
Intake form thumbnail image

HCRQI is responsible for processing complaints for certain types of health care facilities and agencies. View a list of facility or agency types HCRQI oversees in the Regulated Facility Types section. If the facility type is on the list, please file a complaint with our office per the instructions below. If the facility type is NOT on the list, please use this Complaint Referral List (pdf) to help you find the appropriate program for your complaint.

  1. Click on the Complaint Intake form link (below), this will direct you to the PDF form.
  2. You may complete the form directly online or save and print for future use.
  3. If you choose to complete online, please complete this form as thoroughly as possible.
  4. Print the form and submit to our office (Health Care Regulation and Quality Improvement) by mail, e-mail or fax.

Complaint Intake Form (pdf) 
Public Records Disclosure Form (pdf)
Complaint Referral List (pdf)

Submit completed form by mail, e-mail or fax:

MAIL:

Health Care Regulation and Quality Improvement
P.O Box 14450
Portland, OR 97293

Mark clearly on the envelope “Confidential”

E-MAIL: mailbox.hclc@state.or.us                

FAX: (971) 673-0556

If you have any questions regarding this form, please contact our office at (971) 673-0540, and press zero for immediate assistance.


Frequently Asked Questions

1. What happens after I submit a complaint?

The information provided below will be carefully reviewed against the applicable Oregon Administrative Rules and/or Code of Federal Regulations for the specific facility or agency type this complaint is about. The review will determine if there are potential violations of those requirements and if this is the office with jurisdiction to take further action. You will be notified in writing of the results of the review. The letter will inform you what action this office has authority to take, which may include an unannounced, onsite investigation. If it is determined that the concerns fall under the jurisdiction of another agency or organization the letter will provide you with that information

2. Is my personal and complaint information kept confidential?

Your identity as the complainant is maintained confidentially. This office is prohibited from releasing complainant information and the complaint systems are designed to protect that anonymity.

3. If an investigation is completed, how do I request a copy?

Please complete a Disclosure of Records Form (pdf). Please note that if you are requesting a copy of The Statement of Deficiencies report and the provider's Plan of Correction regarding a complaint investigation the records will be available for public disclosure no later than 90 calendar days from the date of the investigation. Please include the name of the health care provider and the complaint investigation number in your request.