Complaint Tracker System

Online Complaint Submittal Form - Long Term Care Licensing

The Division of Licensing Services, Bureau of Long Term Care Licensing provides this Online Complaint Form which allows anyone with knowledge or concerns about a suspected rule violation to submit a complaint through this web page. A complaint is a suspected violation of Arizona state rules and/or statutes governing the operations of licensed Long Term Care Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID).

Please review the following prior to submitting the complaint allegation.

Complaint Frequently Asked Questions (FAQs)

When filling out this form, information that is required is indicated by a red asterisk (*). Click "Start" to begin complaint.

Enter Complaint Information

* Start Date and Time of Alleged incident/Violation

End Date and Time of Alleged incident/Violation

* Describe what happened, including when (time and date), and how, who was involved, and if this happened before.

Please attach any evidence such as supporting documentation or pictures relevant to the complaint.

* Is Evidence Available?

Yes No

* Has the licensee/owner and/or manager of the facility been contacted?

Yes No

* Have any other agency (Ombudsman, APS, AHCCCS, police, etc) been contacted?

Yes No

Please add any individuals such as resident, patient, witness, staff member, etc. or specific locations where the complaint occurred.

Enter Complainant's Information

If you are making a complaint; State Law at A.R.S 41-1010 requires that a name of the Complaint shall be public record unless the affected agency determines that the release of the Complainant's name may result in substantial harm to any person or to the Public Health safety.

* Are you submitting anonymously?

Yes

Please note Full name and contact information is still required to submit complaint. Although anonymous reports are accepted, we request your contact information so that we may contact you if we need additional information to properly address your complaint.

* Do you feel that the release of your name may result in substantial harm?

Yes No

* First Name

* Last Name

Contact Information

Please enter a contact email - You will receive an email at this address to verify your complaint submission

* Email Address

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* Primary Phone Number

Alternate Phone Number

May leave a message at the phone number provided

Address (Number & Street)

Address 2 (Number & Street)

City

State

Zip

* Complainant Source

Please provide me the final determination

* By submitting this form electronically, I state that I have read the complaint contents and the statements are true by my personal knowledge or I believe them to be true.