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Grievance Form

Date of Submission*

Month

Day

Year

Patient Information

First name*

Last name*

Birthday*

Month

Day

Year

Incident Details

Date and time*

Month

Day

Year

Time

:HoursMinutes

Location: *

Park Rapids

Detroit Lakes

Name(s) of Staff Involved: *

Annette Pratt, PMHNP

Mackenzie Snortum, PMHNP

Michelle Hensel, Office Manager

Abby Hines, Office Support

Nature of Complaint

Please check all that apply:

Access to Care: Difficulty scheduling appointments, long wait times, etc.

Quality of Clinical Care: Misdiagnosis, improper treatment, delay in care, etc.

Professional Conduct: Unprofessional, rude, or disrespectful behavior by staff

Billing/Administrative: Discrepancies in billing, registration issues, etc.

Patient Rights: Violation of patient rights.

Facilities/Environment: Issue with facility safety, cleanliness, etc.

Communication: Poor communication from staff or between departments.

Other

Detailed Description of the Incident*

In your own words, please explain what happened. Include specific details like dates, times, and names. Describe the impact the incident had on the patient.

Supporting Documentation

Please list and attach any documents that support your grievance (e.g., medical records, correspondence, bills).

Upload Supporting Documents

Desired Resolution*

What outcome are you hoping to achieve from this grievance? (e.g., apology, refund, review of the incident, specific action to prevent future issues)

Signature*

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Park Rapids Office

1011 1st Street East

Suite 5

Park Rapids, MN 56470

Detroit Lakes Office

808 Washington Avenue

Suite 15A

Detroit Lakes, MN 56501

Phone (320) 321-9599

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