APS

Alleviate Pain and Spine

Patient Complaint / Grievance Form

Internal use only — complete at time of complaint receipt.

Section 1 — Patient Information

Patient full name *

Date of birth *

Date of initial visit

Date of complaint *

Method of receipt *

In-Person Phone Written Email Other

Section 2 — Complaint Category

Check all that apply *

Billing / Insurance / Coding Patient Scheduling / Appointments Unanswered Calls / Messages Clinical / Provider Complaint Staff Conduct / Customer Service Wait Time / Facility Environment Medical Records / Privacy (HIPAA) Prescription / Medication Issue Other

If “Other” — describe

Section 3 — Complaint Description

Detailed description of complaint / grievance *

Sends a full summary to info@alleviatepainandspine.com

RECEIVED

This complaint has been routed to info@alleviatepainandspine.com for review.

No further action is needed from you unless the office manager follows up.

Confidential — internal use only · Alleviate Pain and Spine · Retain per records retention policy