Part 1 - I would like to bring a complaint to the attention of the Commissioner
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for someone elseon behalf of myself
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Has the person (the consumer) who received the service given you permission to make a complaint on their behalf?
YesNoThe person is deceased
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If the consumer has NOT agreed, briefly explain why and outline your interest in the matter:
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(move to part 2)
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Part 2 - Consumer. Details of the person who received the service
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Title
Surname *
Given name*
Daytime phone number *
Email address *
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Address *
Suburb *
Postcode *
Date of Birth
Gender*
MaleFemaleOther
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What is your preferred language?
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Do you need an interpreter?
YesNo
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Optional statistical information
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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)
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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
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Title
Surname
Given name
Daytime phone number
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Address
Suburb
Postcode
Email address
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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)
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Part 4 - Provider of the Service (the person or organisation that gave the health or community service
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Title
Surname *
Given name*
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Name of Organisation*
Type of Service Provider
Daytime phone number
Email address
Suburb
Postcode
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Part 5 - The Complaint
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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
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Main Concerns*: Why are you dissatisfied with the service you received? Please be specific
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Part 6 - Statutory Time Limit
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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.
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If the incident occurred more than 2 years ago, please supply the reason for your delay in making this complaint:
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Part 7 - Other attempts to resolve your complaint
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Have you already tried to resolve your complaint directly with the provider?
YesNo
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Please tell us what happened or your reasons for not trying this approach
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Part 8 - Desired Outcomes
What do you hope to achieve by making a complaint?
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Part 9 - Release of information
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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.
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Part 10 - Referral of complaint
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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
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If you have chosen NOT to give your authorisation and permission in Parts 9 and 10 above, please outline your reasons:
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If you have a file you would like to append to this complaint, please attach it using the browse button.
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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
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