Center for Improvement in Healthcare Quality CIHQ Accredited Hospital Complaint/Concern Reporting Center


	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:
* Address:
* City:	* State: * Zip:
* Date of Incident:
* Approximate Time of Incident:	AM PM
Your IP Address:	100.24.209.47
* 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