This form is designed as a general form for use with respect to all claims. Some of the questions may not be applicable to your particular claim.We respect the dignity and pride of each individual we serve. Learn more about your rights and responsibilities as our patient. Our goal is a positive patient experience and health outcomes so you can get back to your friends, family, and life. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. A complaint must contain "a short and plain statement of the claim showing that the pleader is entitled to relief . . . . There are two options for submitting health care complaint forms – either an online electronic complaint form or a printable PDF form. Home page for the New York State Department of Health. There wasn't any laborious paper work to fill out as a first time patient.