Get patient feedback form template

O H S U Pat i e n t R e l at i o n s Patient Feedback Form Patient name please print Date of birth Address Phone Cell Submitted by Medical record no. if known This concern is regarding my bill Yes No 1. Did you discuss this concern with a member of your health care team 2. Please write a brief statement Who was involved When did the issue occur What happened Use back of form if necessary and/or attach related documents I authorize the OHSU Patient Advocate to review the above concern and advocate on my behalf* I understand the advocate will review my medical record and/or discuss my case with my OHSU health care provider s. Signature of patient or guardian Date Return to OHSU Patient Relations Dept. UHS-3 3181 S*W* Sam Jackson Park Rd Portland OR 97239 Telephone 503 494-7959 Fax 503 494-3495 www. ohsu. edu/advocate If we still have not addressed your concern the following resources are also available to assist you State of Oregon Health Care Licensure and Certification Section 971 673-2700 State Quality Improvement Organization Acumentra Health 1 800 633-4227 The Joint Commission Office of Quality Monitoring 1 800 994-6610 complaint jointcommission*org Confidential In accordance with ORS 41. if known This concern is regarding my bill Yes No 1. Did you discuss this concern with a member of your health care team 2. Please write a brief statement Who was involved When did the issue occur What happened Use back of form if necessary and/or attach related documents I authorize the OHSU Patient Advocate to review the above concern and advocate on my behalf* I understand the advocate will review my medical record and/or discuss my case with my OHSU health care provider s. Please write a brief statement Who was involved When did the issue occur What happened Use back of form if necessary and/or attach related documents I authorize the OHSU Patient Advocate to review the above concern and advocate on my behalf* I understand the advocate will review my medical record and/or discuss my case with my OHSU health care provider s. Signature of patient or guardian Date Return to OHSU Patient Relations Dept. UHS-3 3181 S*W* Sam Jackson Park Rd Portland OR 97239 Telephone 503 494-7959 Fax 503 494-3495 www. Signature of patient or guardian Date Return to OHSU Patient Relations Dept. UHS-3 3181 S*W* Sam Jackson Park Rd Portland OR 97239 Telephone 503 494-7959 Fax 503 494-3495 www. ohsu. edu/advocate If we still have not addressed your concern the following resources are also available to assist you State of Oregon Health Care Licensure and Certification Section 971 673-2700 State Quality Improvement Organization Acumentra Health 1 800 633-4227 The Joint Commission Office of Quality Monitoring 1 800 994-6610 complaint jointcommission*org Confidential In accordance with ORS 41. if known This concern is regarding my bill Yes No 1. Did you discuss this concern with a member of your health care team 2. Please write a brief statement Who was involved When did the issue occur What happened Use back of form if necessary and/or attach related documents I authorize the OHSU Patient Advocate to review the above concern and advocate on my behalf* I understand the advocate will review my medical record and/or discuss my case with my OHSU health care provider s. Signature of patient or guardian Date Return to OHSU Patient Relations Dept. UHS-3 3181 S*W* Sam Jackson Park Rd Portland OR 97239 Telephone 503 494-7959 Fax 503 494-3495 www.