Facilities Complaints

Public Health

What would you like to do?

What you need to know

Instructions:

Do NOT reply to this email address as it is an unmonitored account. If you have questions or would like to follow up on your form submission, please email DHHS.HealthFacilityInvestigations@nebraska.gov or Fax 402-742-2389

Please furnish all identifying information for the complainant, the patient, resident or client and facilities involved in the complaints.

Submit to: Nebraska Department of Health and Human Services Licensure Unit

Attention: Health Facility and Service Investigations

Online Complaints regarding: Health Facilities and Services and/or Nurse Aides/Medication Aides licensed by the State of Nebraska

PERSON MAKING COMPLAINT

Name

Address

City

State

Zip Code Format: 99999

Home Phone(including area code)

Work Phone(including area code)

Mobile Phone(including area code)

Email:

Relationship to Resident, Patient, or Client

May we contact you at your place of employment?

PATIENT, RESIDENT, CLIENT INFORMATION

Name:

Date of Birth

Date of Incident

This Complaint is being filed against:

Facility Name:

Facility Address

City

State

Zip Code Format: 99999

* Narrative (Required): Please describe in detail all allegations against the facility(ies). Describe each incident with specific dates and list any witnesses.

Send additional supporting information related to this report to email:

DHHS.HealthFacilityInvestigations@nebraska.gov or Fax 402-742-2389

Thank you for your submission someone will contact you if they have questions

Your bid submission did not go through please contact program manager and report the time of failure.

Submit

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What would you like to do?

What you need to know

Facilities Complaints