File A ComplaintPlease use the form below to submit your complaint to our office. We’ll be in touch shortly. Name * First Name Last Name Email * Phone (###) ### #### City What is your relationship to the resident/patient? Resident's Name * First Name Last Name Facility Name * Facility State * Facility City * Facility County Name of Resident’s Power of Attorney or Guardian First Name Last Name Does the resident know you’re contacting the LTC Ombudsman for assistance? Yes No Does the resident still reside in the facility named above? Yes No Please explain the nature of your concern or complain Thank you!
