National Alliance of Methadone Advocates
CONFIDENTIAL
Grievance/Compliment Report

All information that is provided will be held strictly confidential in the same manner as the patient protections described in the U.S. Federal Confidentiality Regulations 42 CFR and the Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) as established by the Department of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In order to assist you at the maximum level of follow-up and outcome, we do request certain personal information below. However, if you do not want us to disclose your name for any reason, we will honor your wishes.
Information on Person Filing Report

Name:  _____________________________________________________________________________

Address:  ___________________________________________________________________________

City:  ________________________  State/Providence: ____  Zip/Postal Code: _____ Country:_________

Phone:  __________________________________    Fax:  ___________________________________

Other Phone:  _______________________________  Email:  ________________________________
If we contact the clinic or agency do you want to be informed of the results? (If by mail please include a self-addressed envelope.)   Yes  ________  No  ________

Information About Agency Under Report

Name of Clinic/Agency:  ______________________________________________________________

Address:  _________________________________________________________________________

City:  _____________________   State/Providence:  _____   Zip/Postal Code:  ______   Country:  ______

Phone:  __________________________________      Fax:  __________________________________

Name/Title of Person to Contact:  ______________________________________________________

Type of Program/Agency, Check Only One:
Program
Supportive Services
State Agency
Other _____________________________
Information About Incident
Category of Incident Choose One Below: 		Date of Incident: ____________________
Threat of Termination/Discharge
Dosage Policies
Urine Testing Procedures
Punitive Staff
Medication Hours or Schedule
Pick-up Schedule Problems
Unfair or Exorbitant Cost of Treatment
Other, describe: __________

Please Describe Incident in a Concise Way.





















By filing an Grievance/Compliment Report you are helping NAMA keep track of programs and how they are operating. If you need help you should contact NAMA immediately at (212) 595-6262. NAMA does investigate all Grievance/Compliment Reports and discusses patterns of Grievances with regulatory agencies and professional organizations.

Policies that are beneficial or incidents that were managed well by a program may also be reported. These reports will be used to demonstrate alternative policies that can be used by programs and to commend the program that has developed and used them.

Please complete and mail to: Tony Scro, Grievance Coordinator
Email: tonycold@aol.com
National Alliance of Methadone Advocates
435 Second Avenue
New York, NY 10010
Phone/Fax: (212) 595-nama

Together, we can make a difference.

NAMA Information                 Investigator: _________________________________________

Date Received:

Date Completed:          Report  Yes ___ No ___     Initial Upon Completion ________

Comments:




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National Alliance of Methadone Advocates
wwww.methadone.org   Last Update: August 25, 2003