Making a complaint Complaint resolution
Information for the provider

Make a complaint online

    Part 1 - I would like to bring a complaint to the attention of the Commissioner
    for someone elseon behalf of myself
    Has the person (the consumer) who received the service given you permission to make a complaint on their behalf?

    YesNoThe person is deceased

    If the consumer has NOT agreed, briefly explain why and outline your interest in the matter:

    (move to part 2)

    Part 2 - Consumer. Details of the person who received the service


    Surname *

    Given name*

    Daytime phone number *

    Email address *

    Address *

    Suburb *

    Postcode *

    Date of Birth


    What is your preferred language?

    Do you need an interpreter?

    Optional statistical information
    Are you a member of ANY of the following groups?

    AboriginalTorres Strait Islander
    Non-English speaking background
    (please state your ethnic background)
    A person with a disability
    (please specify disability)

    If you are lodging a complaint on behalf of the consumer, please make sure Part 3 is completed.
    If you are lodging the complaint yourself, please move to Part 4

    Part 3 - Complainant Information - the person who is making the complaint on behalf of the consumer



    Given name

    Daytime phone number




    Email address

    What is your relationship with the consumer?
    Parent/GuardianA health or community service providerOther relative (state relationship)

    Appointed representative of the consumerAn advocate or professional representativeOther (please state eg. carer)

    Part 4 - Provider of the Service (the person or organisation that gave the health or community service


    Surname *

    Given name*

    Name of Organisation*

    Type of Service Provider

    Daytime phone number

    Email address



    Part 5 - The Complaint

    Background Information*: What actually happened that led to you making this complaint? If possible, please supply a brief summary / background to your situation with critical dates, times and locations

    Main Concerns*: Why are you dissatisfied with the service you received? Please be specific

    Part 6 - Statutory Time Limit

    Date when the service was provided:
    Unless there is good reason for a delay, the Commissioner cannot accept a complaint about a service which occurred more than 2 years ago.

    If the incident occurred more than 2 years ago, please supply the reason for your delay in making this complaint:

    Part 7 - Other attempts to resolve your complaint
    Have you already tried to resolve your complaint directly with the provider?
    Please tell us what happened or your reasons for not trying this approach

    Part 8 - Desired Outcomes

    What do you hope to achieve by making a complaint?

    Part 9 - Release of information
    To assess a complaint adequately, it may be necessary for us to obtain information such as medical records. To do this we require your permission to request information and the provider requires your consent to release it.

    By ticking the box YES, I authorise the Commissioner for Health and Community Services Complaints or his/her delegate to access all or any information relating to my complaint, including medical records and any other information within the knowledge or possession of the provider/s named in this complaint form and I HEREBY EXPRESSLY AUTHORISE AND DIRECT such providers to release to the Commissioner or his/her delegate such information as may be requested by him/her in relation to my complaint.

    Part 10 - Referral of complaint
    We usually send a copy of the complaint to the provider for a response. We seek your permission to do this and also to refer this complaint, where appropriate, to another body.


    By ticking the box YES, I authorise the Commissioner for Health and Community Services Complaints to forward a copy of my complaint to the provider or another person/body if required

    If you have chosen NOT to give your authorisation and permission in Parts 9 and 10 above, please outline your reasons:
    If you have a file you would like to append to this complaint, please attach it using the browse button. If you have several files you wish to append to your complaint, please email them separately to

    Please tick this box if you are sending additional files by email

    Details of the person filling in this form (a copy of your completed form will be emailed to you)

    Your first name*

    Your last name *

    your email address *

    Form verification

    Please enter your last name again: