HCS Complaint - IMPROV

Home Care Services Provider On-Line Complaint Form

Complaint Date

10/25/2021

Participant's Name

Your Relationship with the Participant

Select The Waiver The Participant Is Served By (if known)

Select The Provider That The Complaint Will Be Filed Against

(Please Enter Your Information So We May Contact You)

Name

Address

City

State

Zip

Phone

* Note: After you select "Submit" you will go to a Confirmation page where you will be able to Print your Complaint.