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 else on behalf of myself(move to part 2) Has the person (the consumer) who received the service given you permission to make a complaint on their behalf?
 Yes No The person is deceased

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


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

Title

Surname *

Given name*

Daytime phone number *

Email address *

Address *

Suburb *

Postcode *

Date of Birth *

Gender*
 Male Female Other

What is your preferred language?

Do you need an interpreter?
 Yes No


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

Title

Surname

Given name

Daytime phone number

Address

Suburb

Postcode

Email address

What is your relationship with the consumer?
 Parent/Guardian A health or community service provider Other relative (state relationship)

 Appointed representative of the consumer An advocate or professional representative Other (please state eg. carer)


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

Title

Surname *

Given name*

Name of Organisation*

Type of Serivce Provider

Daytime phone number

Email address

Suburb

Postcode


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?
 Yes No
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.
 Yes

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.

 Yes

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 hcscc@nt.gov.au

 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: