Form 504 - Recipient Rights Complaint Form
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1
2Michigan Department of Licensing and Regulatory Affairs
LARA/SUB-
504 (5/13)
Bureau of Health Care Services
To Be Completed By Rights Advisor:
Health Facilities Division
Program Name
Substance Abuse Program
P.O. Box 30664
License Number
Lansing, MI 48909
(517) 241-1970
Complaint Number
RECIPIENT RIGHTS COMPLAINT FORM
Date Received by Rights Advisor
Authority: Public Act 368 of 1978, as amended
Date Report Due to Recipient
1.
DESCRIBE YOUR COMPLAINT: (Does your complaint involve a person, a procedure, or the building the
program is in? Give names of witnesses or other details that will help your rights advisor understand your
complaint). Attach additional paper if necessary.
2.
Where did it happen? (Address or Location):
3.
When did it happen? (Date (MM/DD/YY) and Time)
4.
What right(s) do you think were violated?
5.
What would you consider to be a fair solution to this problem? (What do you want done, by whom and
by when?
6.
How do you want to get your copy of the investigation report on this complaint? (Check one)
PICK UP in rights’ advisor’s office with 30 working days. When report is ready, please call me at:
______________________
(Telephone Number w/area code)
MAIL to me at the following address by registered mail:
________________________
Street Address
City
State
Zip Code
Recipient’s Signature (must also sign authorization to release information on Page 2).
Signature: ______________________________________________________
Date: _________________
Rights Advisor’s Signature: ____________________________________________________________________
Printed Name: _________________________________________________
Date: ________________
Copies to: 1) Program
2) LARA/BHCS/SUBSTANCE ABUSE
3) Coordinating Agency
Page 1 of 2
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