EmailMeForm
HMCDDO Complaint Form
A "complaint" is any grievance, appealable action, or dispute resolution received by the HMCDDO or KDADS regarding a decision or action taken by the HMCDDO or Affiliate provider, if reported to KDADS or the HMCDDO.
Consumer Name
*
First
MI
Last
Guardian Name (if applicable)
First
Last
Email
*
Type of Complaint
*
Please select
Complaint Regarding Affiliated Service Provider
Eligibility Determination
Functional Assessment
Funding Issues
Other
Complaint Narrative:
*
Complainant Signature
*
Clear
Complainant Name
*
First
MI
Last
Date
*
MM
/
DD
/
YYYY
