ࡱ> [ 4bjbj   :  Patient Grievance Form As a patient of Riverside University Health System our goal is to provide care and services in a manner that is respectful of your rights and needs. If a concern should develop while you are at our facility, please ask to speak with a member of the health care team so that we may attempt to resolve the issue or concern immediately. How to File a Grievance You may also file a grievance. Your grievance will be investigated and you will receive a written response from us within seven (7) business days of our receipt of the grievance. We will notify you in writing if the issue or concern will require more time to resolve. You can file a grievance in one of the following methods: In person (business hours: Monday Friday 8:00 a.m. 4:30 p.m.) Telephone call which will be documented by our office: 951- 486 - 4313 English and Spanish 951- 486-4397 TDD Fax 951-486-6569 Online, at our website: RUHealth.org Letter at the address below: Riverside University Health System Hospital Administration 26520 Cactus Avenue Moreno Valley, CA 92555 Grievances can also be directed to the California Department of Public Health: California Department of Public Health Services, 625 E Carnegie Drive, Suite 280, San Bernardino, CA 92408 (909) 388-7170 Patients Name: Date: Medical Record Number: Telephone Number: Alternate Telephone Number: Name of person filing if different than patient: Relationship to Patient:Address: Insurance Type: Department/Location where issue/concern occurred: Date occurred: Signature:Please describe the nature of the issue or concern on the back of this sheet:     Return completed form to ADMINISTRATION CONFIDENTIAL & PRIVILEGED Form 313;2012 3KO Z e g h i   3 5 ׹ׯ}s}i\hihOJQJ^Jh@xZOJQJ^JhOJQJ^Jh#OJQJ^JhihCOJQJ^JhihOJQJ^Jh Xh,i25OJQJ^JhCOJQJ^Jh,i2OJQJ^Jh9OJQJ^Jh&OJQJ^JhOJQJ^J#h XhP5CJOJQJ^JaJhiU~jhiU~U h i B l ~  & F-DM gdI & F-DM gdI & F-DM gdC & F-DM gd@xZ$-DM a$gd2:$a$gd,i2gdC$a$gd2:$-DM a$gdiU~ A B S h k l y } ~ Ⱦ|obSGo=hgUZOJQJ^Jhu@OJQJ^Jh hI@OJQJ^Jh h OJQJ^Jh hIOJQJ^JhKzPhCOJQJ^JhC@OJQJ^JhChC@OJQJ^JhCh@xZOJQJ^JhChCOJQJ^JhCOJQJ^Jh@xZOJQJ^Jh2h@xZOJQJ^Jh2OJQJ^Jh2hOJQJ^JhIOJQJ^J 9 : ; < b    {qg{qZPChiU~h#$OJQJ^Jh1%sOJQJ^JhThTOJQJ^JhteOJQJ^JhyOJQJ^JhihyOJQJ^Jhgj@OJQJ^J hihCJOJQJ^JaJ hih@xZCJOJQJ^JaJhhOJQJ^Jhhh=(OJQJ^JhOJQJ^JhhTWOJQJ^JhOJQJ^JhIOJQJ^Jh dOJQJ^J 9 ;      7 ; $Ifgdk ^`gdiU~ ^`gdte & Fgdte -DM gd#$$-DM a$gd^L p^p`gd & F-DM gd        ! 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