Michigan Department of Community Health
RECIPIENT RIGHTS COMPLAINT
If you believe that one of your rights has been violated you (or someone on your behalf) may use this form to make a complaint. A rights officer/advisor
will review the complaint and may conduct an investigation. Keep a copy for your records and send the original to the right office at the CMH agency or
the hospital where you are receiving (or received) services, or to: MDCH - Office of Recipient Rights, Lewis Cass Building, Lansing, Michigan 48933
Recipient’s Name (if different from complainant):
Where did the alleged violation occur?
Complainant’s Phone Number:
When did the alleged violation happen? (date and time):
What right was violated?
Describe what happened:
What would you like to have happened in order to correct the violation?
Name of Person Assisting Complainant
DCH 0030 Replaces DCH-2500 Authority: P.A. 258 of 1974 as amended
Distribution: ORIGINAL TO ORR
COPY to Complainant (with acknowledgement letter)