Complaint Report Form
Holistic Healthcare Management Services – Feedback, Formal Complaints, and Provider Investigation Framework.
Register No. (office use): _________________
Introduction & Process Overview
Dear Participant,
We greatly value your feedback as it helps us continuously improve the quality of services we provide. Please use Part 1 of this form to share any feedback on your experience with our service.
If you have concerns, are dissatisfied, or believe you have been mistreated by Holistic Healthcare Management Services, you are encouraged to make a formal complaint by completing this form. Any individual receiving services from Holistic Healthcare Management Services is entitled to submit a formal complaint, which can lead to enhanced services and improved quality of care for all.
Upon receipt of your complaint, we will acknowledge it within one (1) business day of the submission date. If there are any delays in addressing your complaint, one of our representatives will contact you with a tentative date by which we will respond.
Should you require assistance in completing this form, please do not hesitate to contact our friendly staff.
Anonymous Feedback or Complaint
If you prefer to raise a complaint anonymously, you can do so by following one of the options below:
- Complete Part 1 of this form, selecting “Anonymous” in Section A and leaving the personal information fields in Section B blank. Completed complaint forms can be mailed directly to Holistic Healthcare Management Services.
- Make an anonymous phone call to us at 0455055537 and inform our representative that you wish for the complaint to remain anonymous. Our representative will not request any personal information that could identify you.
If this complaint is similar or identical to one made previously, please provide details about when the last complaint 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. If you wish for the complaint to remain anonymous, please specify this before the complaint is documented.
Escalation & Support
Alternatively, you may escalate your complaint directly to the NDIS 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.
If you feel comfortable, we encourage you to raise your concern or complaint with Holistic Healthcare Management Services first, as this is often the most efficient way to resolve your issue quickly.
PART 1 – FEEDBACK
We believe our frontline staff are the best people to assist you. If you want to provide feedback about the quality or safety of our services/supports, please feel free to complete all sections below.
We would love to hear your thoughts or feedback on how we can improve your experience. Your feedback comments are covered by our Privacy and Confidentiality Policy and Procedure. Please note Holistic Healthcare Management Services takes privacy seriously and will only collect, hold, use and disclose your personal information in compliance with the Privacy Act.
If filing 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 the feedback on behalf of the NDIS Participant or a person with a disability | ☐ |
| Anonymous: You are providing anonymous feedback and won’t 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:
| NDIS Participant | ☐ |
| Family member | ☐ |
| Carer | ☐ |
| Friend | ☐ |
| Guardian | ☐ |
| Advocate | ☐ |
| Other: __________________________________________ | ☐ |
Section D. Your feedback
| Please provide details about your feedback: |
Section E. Your signature
| Your signature: | |
| Date: |
