DPH Ticketing System

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Anyone with knowledge or concerns about the care of a patient/resident in a licensed healthcare facility may file a complaint with their State Survey Agency. Facility Licensing and Investigation Section (FLIS) is the agency that has regulatory oversight for all the licensed healthcare entities in the state.

You may click this link FLIS Complaint Submission to file a complaint if you are concerned about the health care, treatment, or services that you or another person received or did not receive in the facility. Some reasons for filing a complaint would include abuse, neglect, poor care, not enough staff, unsafe or unsanitary conditions, dietary problems, or mistreatment.

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First name of the submitter: *

Last name of the submitter: *

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Employee ID *

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Phone Email

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Clinic Name:

Name of organization/provider/local health department *

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Local health department/district*

Role at local health department/district*

Facility Type *

Facility Name *

Care Partner Name *

CVP PIN

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Date Cyberthreat Started*

Date Cyberthreat Ended*

Please do not include Personal Identifiable Information (PII) in your description.

Please specify the group of people, period of time and vaccine measures requested, and how you intend to use the data. Please include a date needed by, if applicable.

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You should receive an acknowledgement of your request within 2 business days.

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Important: Please do not attach any Personally Identifiable Information (PII) in your attachment(s).This includes but is not limited to name, phone number, address, date of birth and medical record number. You can only upload PDF, GIF, PNG, JPG, XLS, XLSX, DOC, DOCX files.

DEPARTMENT OF PUBLIC HEALTH

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