Complaint Report Form
Holistic Healthcare Management Services – Feedback, Formal Complaints, and Provider Investigation Framework.
Register No. (office use): _________________
Introduction & Process Overview
Dear Participant,
We appreciate your input to help us continually improve the quality and safety of our services. Please use Part 1 of this form to provide any feedback about your experience with our service.
If you are concerned, unhappy with, or believe you have been mistreated by Holistic Healthcare Management Services, you are encouraged to make a formal complaint by completing this form. A formal complaint can be submitted by anyone receiving services from Holistic Healthcare Management Services, and raising a complaint can result in better services and quality of care for everyone.
Once we receive your complaint, we will acknowledge receipt within one (1) business day of the submission date. If there are any delays in responding to your complaint, one of our representatives will contact you and provide an indicative timeframe for our response.
A formal investigation will commence once we receive this form. If you require assistance completing this form, please contact our staff and we will be happy to help.
Anonymous Feedback or Complaint
If you want to raise a complaint or provide feedback anonymously, this form can be submitted by doing one of the following:
- (i) Fill out Part 1 of this form and select “Anonymous” in Section A and do not fill out your personal information in Section B. Completed forms can be mailed directly to: [ADD ADDRESS]
- (ii) Make an anonymous phone call directly to us on [ADD CONTACT NUMBER] and inform our representative that you wish for the complaint to remain anonymous. Our representative will not request any personal information that may identify you.
If this complaint is similar or identical to one made previously, we encourage you to provide information about when the last complaint form was submitted in Part 2 – Section E.
Complaints can also be made in person through a face-to-face discussion with one of our representatives. These can remain anonymous on request, but this must be stated before the complaint is documented.
Other Ways to Raise a Complaint
Alternatively, you may raise or escalate your complaint directly to the NDIS Quality and Safeguards Commission by:
- Phone: 1800 035 544 (free call from landlines) or TTY 133 677. Interpreters can be arranged.
- National Relay Service and ask for 1800 035 544.
- Completing a complaint contact form on the NDIS Commission website.
If you feel comfortable, we encourage you to raise your concern or complaint with Holistic Healthcare Management Services first, as this is often the quickest way to resolve your issue.
Part 1 – Feedback
We believe our frontline staff are often best placed to assist you. If you want to provide feedback about the quality or safety of our services/supports, please complete the sections below.
Your feedback is covered by our Privacy and Confidentiality Policy and Procedure. Holistic Healthcare Management Services takes privacy seriously and will only collect, hold, use and disclose your personal information in accordance with the Privacy Act 1988 (Cth) and relevant state or territory laws.
If filling out this form by hand, please use a BLACK or BLUE pen and mark ‘X’ in relevant boxes.
Section A. About the feedback
| Direct: You are an NDIS Participant or Client providing feedback directly. | ☐ |
| Indirect: You are providing feedback on behalf of an NDIS Participant or a person with disability. | ☐ |
| Anonymous: You are providing anonymous feedback and will not reveal your name or contact details. | ☐ |
Section B. Your details
| First Name: | ____________________________________________ |
| Last Name: | _____________________________________________ |
| Contact Number: | ________________________________________ |
| Email Address: | _________________________________________ |
Section C. Who are you?
I am submitting as (select one):
| NDIS Participant | ☐ |
| Family member | ☐ |
| Carer | ☐ |
| Friend | ☐ |
| Guardian | ☐ |
| Advocate | ☐ |
| Other: _______________________________________________ | ☐ |
Section D. Your feedback
| Please provide details about your feedback (what happened, what worked well, what could be improved): |
Section E. Your signature
| Your signature: | ______________________________________ |
| Date: | ______________________ |
| (If submitting anonymously, leave this section blank.) | |
Part 2 – Complaint
With the information you provide below, we will work with you to resolve your complaint or concern. Holistic Healthcare Management Services takes privacy seriously and will only collect, hold, use and disclose your personal information in compliance with the Privacy Act and our internal policies.
If filling this form out by hand, please use a BLACK or BLUE pen and mark ‘X’ in relevant boxes.
Section A. About the complainant
| Direct: You are an NDIS Participant or Client making the complaint directly. | ☐ |
| Indirect: You are making the complaint on behalf of an NDIS Participant or a person with disability. | ☐ |
| Anonymous: You are making an anonymous complaint and will not reveal your name or contact details. | ☐ |
Section B. Your details
| First Name: | ____________________________________________ |
| Last Name: | _____________________________________________ |
| Phone Number: | _________________________________________ |
| Email Address: | _________________________________________ |
| (If anonymous, leave Section B blank.) | |
Section C. Who are you?
I am submitting as (select one):
| NDIS Participant / Client | ☐ |
| Family member or friend | ☐ |
| Advocate | ☐ |
| Carer | ☐ |
| Staff member | ☐ |
| Other: _______________________________________________ | ☐ |
Section D. Assessing the need for any help with communication
| Do you require any help with communication? (e.g., interpreter/translator, Easy Read, Auslan): | ☐ Yes ☐ No |
| If Yes, please provide details of the help that you need; otherwise write N/A: |
Section E. Your complaint
| Please provide details about your complaint (what happened, when, where, and who was involved if known): | |
| What outcomes are you seeking as a result of the complaint? (e.g., apology, explanation, change in services, review of decision, training, other): |
Section F. Your signature
| Your signature: | ______________________________________ |
| Date: | ______________________ |
| (If submitting anonymously, leave this section blank.) | |
Part 3 – Provider Actions and Investigation
(To be completed by Holistic Healthcare Management Services’s manager or delegate)
Section A. Immediate action
| Immediate actions and measures taken in response to this issue: | |
| Immediate actions and measures were satisfactory: | ☐ Yes ☐ No |
| Comments: |
Section B. Investigation
| Preliminary findings: | |
| Identified root causes: |
Section C. Required actions
| Description of actions: | |
| Responsible person (full name & position title): | |
| Deadline (DD/MM/YYYY): | ____ / ____ / ______ |
Section D. Review
| Review Date: | ____ / ____ / ______ |
| Status (select one): |
|
| Outcomes (select all that apply): |
|
| Comments: |
Section E. Notification
| Referred to NDIS Commission or other government body: | ☐ Yes – If Yes, date: ____ / ____ / ______ ☐ No |
| Complaint resolved? | ☐ Yes ☐ No |
| Results communicated to the participant and other relevant stakeholders? | ☐ Yes ☐ No |
| Comments: |
Section F. Signature (Provider Representative)
| Full Name: | ____________________________________________ |
| Position Title: | _________________________________________ |
| Date: | ______________________ |
| Signature: | _____________________________________________ |
