Get Nursing Home Compleaint Form Doh-5022 - New York State ...

This guide provides a step-by-step approach to filling out the Nursing Home Complaint Form DOH-5022 online. It ensures that all necessary information is included to facilitate the review of your concerns by the New York State Department of Health.

Follow the steps to complete the form accurately and effectively.

1. Press the ‘Get Form’ button to access the Nursing Home Complaint Form DOH-5022 and open it in your preferred editing tool.
2. Provide your contact information in the designated fields. This includes your first name, last name, address, city, zip code, state, daytime phone number, alternative phone number, and email address. Indicate your relationship to the resident in the corresponding section.
3. Enter the resident's information by filling in their first name, last name, and current location (nursing home, hospital, or other). If applicable, include the date of discharge from the nursing home.
4. Fill in the facility information by providing the nursing home name, address, city, and room number.
5. Complete the complaint information section. Specify the date your concern occurred and indicate whether law enforcement is involved. Also, answer questions regarding the care plan, prior complaint filing, resolution status, and if other residents are affected.
6. Describe your complaint in detail. Include involvement of staff, other residents, and any witnesses to the event.
7. Review the completed form to ensure all fields are filled accurately. You may save your changes, download the form, print it, or share it via email depending on your needs.

Take the next step to ensure your concerns are heard by completing the Nursing Home Complaint Form online.