ARIZONA DEPARTMENT OF HEALTH SERVICES
ADHS Licensing Complaint Submittal Form
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
* 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.
Please add any individuals such as resident, patient, witness, staff member, etc. or specific locations where the complaint occurred.
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.
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.
Please enter a contact email - You will receive an email at this address to verify your complaint submission
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