CASCADE HEALTH CONFIDENTIAL COMPLAINT FORM

Cascade Health’s Confidential Complaint Form is used to document complaints involving a patient’s care.

If you have any questions regarding the complaint form, please reach out to Cascade Health's Compliance Coordinator by phone at (541) 228-3056 or by email at compliance@cascadehealth.org.

Are you a Cascade Health employee or patient/community member?

Cascade Health employee Patient/Guardian/Community member

REMINDER: Patient complaints are never part of the patient's medical record. Please document all information relevant to the complaint within this form.

Employee name:

If you would like to submit an anonymous report, please enter "Anonymous."

Name of complainant:

Patient name if different from complainant:

Your name:

If you would like to submit an anonymous report, please enter "Anonymous."

Date

Complainant’s phone number:

Complaint made by:

Phone In-person Email Mail Other

Other:

Other department (please identify to the best of your ability)

For patients of Counseling & EAP If you feel that your complaint or grievance is likely to cause harm before the normal complaint or grievance procedures are completed, you have the right to an expedited review. Is this something you would like for us to consider?

Yes No

Description of complaint:

What is complainant's desired resolution or outcome?

What is your desired resolution or outcome?

OPTIONAL: Is the complaint related to discrimination on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex, including sex characteristics, intersex traits, pregnancy or related conditions, sexual orientation, gender identity, and sex stereotypes?

Yes No

OPTIONAL: Is your complaint related to discrimination on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex, including sex characteristics, intersex traits, pregnancy or related conditions, sexual orientation, gender identity, and sex stereotypes?

Yes No

Would the complainant like someone to contact them?

Yes No Unsure

Would you like someone to contact you?

Yes No

Your phone number:

Your information will be encrypted.