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: | |||||
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Program |
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Supportive Services | ||
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State Agency |
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Other _____________________________ | ||
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Information About Incident Category of Incident Choose One Below: |
Date of Incident: ____________________ | ||||
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Threat of Termination/Discharge |
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Dosage Policies | ||
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Urine Testing Procedures |
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Punitive Staff | ||
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Medication Hours or Schedule |
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Pick-up Schedule Problems | ||
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Unfair or Exorbitant Cost of Treatment |
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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: |
Claude Hopkins, Grievance Coordinator Email: [email protected] 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: