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 rights office at the CMH agency where you are receiving (or received) services:
LifeWays, Office of Recipient Rights, 1200 N. West Avenue, Jackson, Michigan 49202
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 do you want to have happen in order to correct the problem?
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