If you believe that one of your rights has been violated, you (or someone on your behalf) may use this form to make a complaint. A Rights Officer/Advisor will review the complaint and may conduct an investigation.

Instructions for downloading and submitting the form

The form is available now in Microsoft Word (W) and Adobe Acrobat (PDF).  You will need Adobe Acrobat Reader to be able to view and print this form.  The PDF format can only be printed and filled out by hand.  The Microsoft Word format can be saved to your hard drive or diskette, filled out on your computer, and then printed out and mailed.

1.  Click on the form you want and you will be able to save it to a directory on your hard drive or a diskette. 

Recipient Rights Complaint Form - Microsoft Word Format

Recipient Rights Complaint Form - PDF Format

To get Adobe Acrobat Reader free, click here

2. Print 2 copies once you have the form filled out, keep one for your records and send the other to the RIghts Office at your CMH Service Program, Hospital, or to:

Michigan Department of Community Health
Office of Recipient Rights
Lewis Cass Building
Lansing, MI 48913