Client Complaint/Suggestion Form

(to be completed by the client/client’s family member/care taker)

United Indian Health Services, Inc. welcomes client complaints and/or suggestions as an
opportunity to improve services. All clients have the right to make a complaint(s) or provide
suggestions related to the delivery of health care for any service at any of our sites. Completing this form will not compromise access to future care.

Complaint Form

*Name
*Name optional – if your complaint or suggestion is related to your care, omitting your name could limit our ability to fully investigate the issue or come to a resolution on your behalf
Address
MM slash DD slash YYYY