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Check here, if there are no Issues or Complaints for the quarter stated above.

COMPLAINT INFORMATION
(Multiple complaints can be entered; click the Add Complaint Information button after each complaint)

Date Complaint Received (From Member) :
		(MM/DD/YYYY)
Date of Resolution:
		(MM/DD/YYYY)
Member Information
First Name:
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Date of Birth:
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Type of Complaint: May Check more than one issue per complaint
		Access Issue Communication/Behavior Coordination of Care Technical Competence Facility/Environment Concerns Other Issues
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		Written Verbal
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