Michigan Department of Community Health
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
Complainant’s Name:
Recipient’s Name (if different from complainant):
Complainant’s Address:
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?
Complainant’s Signature
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)
Complaint Number: