Complaint Resolution Form
Patient:
HICN:
Address:
Phone:
Summary Of Complaint
Complaint was:
Verbal
Written
Date Received:
Received by:
Device:
Complaint:
Poor Fit
Poor Quality
Device not working
Other notes:
Summary Of Action
Action Taken:
Replace Device
Refit Device
Return Device
Return for repair
Other notes:
Approved by:
Patient Satisfied
with action taken:
Yes
No
Certification
I certify that I am satisfied with the action taken, to resolve my complaint, upon my behalf by this office.
Patient/Guardian
Date
Witness
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