SCHC Because We Care Form

Because We Care

You, or a person of your choice, have the right to present a grievance, complaint, and suggestion regarding health services to SCHC Administration, who will follow-up and respond in writing within ten (10) working days.

What do you want to report?(Required)

Good Job

Suggestion

Complaint

Incident

Date of report:(Required)

Location:(Required)

(i.e., lobby, exam room)

Who was involved?(Required)

(Names)

Describe the situation:(Required)

(give a detailed description of what happened)

Patient's Name(Required)

(Note: If you choose to withhold the patient’s name, it might hinder an investigation, especially if the description does not include details such as date, time, provider, and witnesses. Thank you.)

Your Name (if you are not the patient)

If you are the patient or parent/guardian of a patient please provide your mailing address for a written response:(Required)

Street Address Address Line 2 City State ZIP Code

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Because We Care

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