Complaints Commission
HCSCC

make a complaint online

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Make a Complaint Online

 

Please fill in and submit the form below

Part 1 - I would like to bring a complaint to the attention of the Commissioner

on behalf of myself (move to Part 2)
for someone else
Has the person (the consumer) who received the service given you permission to make a complaint on their behalf?
Yes  
No  
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:
Address:
Suburb/Town:
Postcode:
Daytime Telephone Number:
Email Address:
Date of Birth:
Male Female
Public Patient Private Patient
Inpatient Outpatient
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:
Address:
Suburb/Town:
Postcode:
Daytime Telephone Number:
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 Service Provider:
Daytime Telephone Number:
Email Address:
Address:
Suburb/Town:
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 on the right.

If you have several files you wish to append to your complaint, please email them separately to hcscc.omb@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:

 

 

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