Complaint Form

Please complete this form to file a complaint about a facility or agency that is licensed by the Division of Licensing & Certification (DLC) or subject to the Division's oversight under the Centers for Medicare and Medicaid Services (CMS) certification. DLC can only investigate facilities or agencies subject to our jurisdiction. The Division of Licensing & Certification will review all material submitted consistent with Chapter 5 (Complaint Procedures) of the CMS State Operations Manual and applicable State policies.

The focus of any investigation is to determine whether the facility or agency, is not in compliance with licensing rules and applicable CMS Conditions of Participation. If the focus of your complaint is in regards to the actions of a licensed individual (Physician, Nurse, Therapist, etc.) you should contact the respective licensing board or agency accordingly, this Division is responsible for investigating complaints regarding the conditions at a facility, agency and unlicensed personnel working at these facilities.

2. Information about you

4. What is the name and address of the facility?

Is the problem ongoing?