DPH FLIS - Facility Licensing & Investigations Section

FLIS Complaint Submission

Report a New Complaint

* - Required Field   
Section 1. Person Filing Out the Complaint Form Information
Section 2. Facility Information
Section 3. Patient Information
 Yes  No  
 Yes  No  Do not know  

Section 4. Complaint Information

Names of any other person(s) or witness(es) involved in this complaint
Person 1 / Witness 1
Person 2 / Witness 2

Section 5. Reporting of Complaint
 Yes  No

Upon Clicking Continue to Review and Submit button you will be able to upload documents/pictures pertaining to this complaint