Proudly Serving Healthcare Organizations Since 1999
CIHQ is a member-based organization comprised of hospitals
and other healthcare entities throughout the United States.
CIHQ Accredited Hospital Complaint/Concern Reporting Center
Please complete the following information.
Your personal information is confidential and will not be shared with the accredited organization without your consent.
Contact Information
* Your Name: 
* Address: 
* City:     * State:    * Zip:
* Telephone: 
* Email: 
* Confirm Email: 
* Are You the Patient: 
* If Answered No Above,   Relationship to the Patient: 
Patient Information
* Name of Patient: 
* Age of Patient:  * Gender:
Accredited Organization Information
* Hospital Name: 
* Address: 
* City:     * State:    * Zip:
* Date of Incident: 
* Approximate Time of Incident: 
Your IP Address:   54.146.59.49
* Location in Hospital (Care   Unit) where Incident Occurred: 
* Please describe the incident or nature of your complaint: (1500 Maximum Characters)
* Does CIHQ have permission to disclose your name/contact information when communicating with the hospital?
* Have you informed the hospital about your incident/concern?
* Do you wish to have CIHQ notify you of the results of our investigation?
*Required fields
Center for Improvement in Healthcare Quality (CIHQ)
P.O. Box 3620
McKinney, TX 75070
Phone: 866-324-5080 | Fax: 805-934-8588

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