NOTE:  Liberty County Hospital & Nursing Home, Inc (doing business as Liberty Medical Center and Wheat Country Estate) will not retaliate against any patient, employee, or observer who registers a complaint concerning medical privacy matters of any kind.  All complaints shall be investigated and resolved to the best possible conclusion.  All matters shall be confidential.  Signing this form is optional; however we may not be able to investigate the complaint fully without your cooperation. 

 

DATE: ________________________                      

 

PATIENT  NAME: ___________________________________  

 

DESCRIPTION OF THE COMPLAINT                                        

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

OPTIONAL:  Signature of person filing complaint                 Date

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INVESTIGATOR’S COMMENTS:                                            

                                                                    

                                                                    

                                                                    

                                                                    

 

ANALYSIS OF PROBLEM:                                                

                                                                    

                                                                    

 

ACTION PLAN: