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Quality Assurance Division
2401 Colonial Drive
PO Box 202953
Helena, MT 59620-2953
FAX: (406) 444-3456
mtssad@mt.gov

Certification and Licensure
On-line Complaint Form

Today's Date:

Date of Complaint:

*Complainant's

Email Address

Relationship to facility:

Family
Resident/Patient
Friend
Employee

Other

Contact Information

Phone:

Address:

City:

State:

Zip:
*
This field is required to help prevent spam - Please us a valid five-digit zipcode.

This Complaint is about: (check all that apply)

Medications Staffing
Quality of Care Administration Issues
Resident Rights Abuse
Environment Discharge of Residents
Other (please specify)

Facility Information

*Facility Name:
City:

Other Individuals who may have information regarding this complaint:

Name and Phone Number:
Name and Phone Number:
Name and Phone Number:

*Specific Allegation(s): Please be objective, specific,
realistic, and complete in your complaint.

The name of the person calling about?  How are you related?

What Happened?


When (date and time) did problem occur?

Is this an ongoing problem?

Is the resident still in the facility?

How did it happen?

Is anyone else involved?
(Staff, family, other residents)

Are there any witnesses?  

Have you taken any actions?

Have you spoken to anyone at the facility?

Is law enforcement involved?

Has the facility tried to address the Situation?

Do you know if this has happened before?

Other information you would like us to know?

If a patient or resident is in imminent danger, please call 911 or the state agency at 406-444-2037. The state agency is staffed Monday through Friday, 8:00 am – 5:00 pm.