HHA Complaint Form indd 2026

1. Click ‘Get Form’ to open the HHA Complaint Form in the editor.
2. Begin by filling out the 'Consumer Information' section. Clearly type or print your name, address, and contact details. Ensure accuracy as this information is crucial for processing your complaint.
3. In the 'Complaint Reported Against' section, provide the name and business details of the individual or organization you are filing a complaint against. Include their license number if known.
4. Indicate your relationship to the consumer or patient by selecting from the provided options such as 'Self', 'Parent', or 'Legal Guardian'.
5. Detail any other practitioners involved by filling out their names, titles, and contact information in the designated fields.
6. Describe the nature of your complaint by checking all applicable boxes and providing additional comments on a separate sheet if necessary.
7. Finally, certify your statements by signing and dating the form before submitting it back to the Division of Consumer Affairs.

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