Online health service complaint form - Office of the Health Ombudsman

Your Details

Title

(Required)

select

First Name

(Required)

Middle Name

Last Name

(Required)

Gender

(Required)

Female
Male
Non-binary/Gender Diverse
Prefer not to answer

Date of birth

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Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

My preferred method of contact

(Required)

select

Phone

Mobile

(If you wish to receive a confirmation email with details of your complaint please enter a valid email address)

Confirm Email

How did you hear about us?

(Required)

select

Other way you heard about us?

Do you identify as Aboriginal and/or Torres Strait Islander?

(Required)

select

Your preferred language?

(Required)

select

Your country of birth?

select

Do you need an interpreter?

(Required)

Yes
No

Do you have any special needs?

(Required)

Yes
No

Please Specify

(Required)

Are you making this complaint on behalf of someone else?

(Required)

Yes
No

Details of the person you are complaining on behalf of

Title

(Required)

select

First Name

(Required)

Last Name

(Required)

Middle Name

Gender

(Required)

Female
Male
Non-binary/Gender Diverse
Prefer not to answer

Date of birth

Open the calendar popup.

What is your relationship to the person you are complaining on behalf of?

(Required)

select

Does the person identify as Aboriginal and/or Torres Strait Islander?

(Required)

select

Has the person asked you to make this complaint?

(Required)

Yes
No

Is the person a child?

(Required)

Yes
No

Has the person died?

(Required)

Yes
No

Date the person died

(Required)

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Are the persons contact details the same as yours?

(Required)

Yes
No

Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

Phone

Mobile

Who is this complaint about?

(Please include as much information as possible)

Health service provider 1:

Is the provider of the health service an individual practitioner or organisation (eg. hospital) ?

(Required)

Individual
Organisation

Health provider's name

(Required)

Type of health service provider

(Required)

select

Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

Health service provider phone

Health service provider mobile

Health service provider email

Can you provide the contact details of someone from the health provider?

(Required)

Yes
No

Title

(Required)

select

Health provider contact first name

(Required)

Health provider contact last name

(Required)

At least one of phone or mobile below must be entered

Health provider contact phone

Health provider contact mobile

Health provider contact email

Health provider contact position

(Required)

Health practitioner's business name

(If Applicable)

Title

(Required)

select

Health practitioner’s first name

(Required)

Health practitioner’s last name

(Required)

Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

Health practitioner's phone

Health practitioner's mobile

Health practitioner's email

Add another health service provider?

(Required)

Yes
No

Health service provider 2:

Is the provider of the health service an individual practitioner or organisation (eg. hospital) ?

(Required)

Individual
Organisation

Health provider's name

(Required)

Type of health service provider

(Required)

select

Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

Health service provider phone

Health service provider mobile

Health service provider email

Can you provide the contact details of someone from the health provider?

(Required)

Yes
No

Title

(Required)

select

Health provider contact first name

(Required)

Health provider contact last name

(Required)

At least one of phone or mobile below must be entered

Health provider contact phone

Health provider contact mobile

Health provider contact email

Health provider contact position

(Required)

Health service organisation's name

(If Applicable)

Title

(Required)

select

Health practitioner’s first name

(Required)

Health practitioner’s last name

(Required)

Street address

(Required)

City/Suburb

(Required)

State

(Required)

select

Post code

(Required)

Health service provider phone

Health practitioner's mobile

Health service provider email

How have you tried to resolve this complaint?

Have you already complained to the health service provider?

(Required)

Yes
No

If you have received a response from the provider, please attach a copy

Attach a copy
You can add up to 5 files (one at a time) with a maximum file size each of 10mb (pdf , rtf , txt , jpg , bmp , gif , png , tif). Please note that the form submission may take a while if you attach large files.

Have you already complained to another entity?

(Required)

Yes
No

Please provide the name of the entity and a reference number if one was provided

Has the complaint been reported to the Crime and Corruption Commission?

(Required)

Yes
No

If yes, please provide a reference number

Comments (e.g. assessed and referred/assessed at Cat 3 referral not required)

Characters remaining 20000

Spell Check

Has the information provided in the complaint been assessed as a public interest disclosure?

(Required)

Yes
No

If yes, who is the discloser

Date the health service was provided

Open the calendar popup.

If the health service was more than two years ago, when did you become aware of the problem?

Open the calendar popup.

Your Complaint

Tell us:

• What concerns happened with the health service • Do you know who was involved • Are you aware of when and where it happened • What are the main issues you are concerned with.

Attach copies of any supporting information—letters, reports, photos, invoices.

Please summarise your complaint

(Required) Characters remaining 20000

Spell Check

Please attach supporting information such as letters, reports, photos, invoices
You can add up to 5 files (one at a time) with a maximum file size each of 10mb(pdf , rtf , txt , jpg , bmp , gif , png , tif). Please note that the form submission may take a while if you attach large files.

What would you like to happen to resolve your complaint?

(Required)

Access
Acknowledgement
Apology
Complaint Recorded
Costs
Explanation
Fees Waived
Information or advice
Policy/process change
Provider education
Records
Refund
Remedial treatment
Response
Treatment or health service
Other

Other Outcome

We will try to help you resolve your complaint and we can do this in a variety of different ways depending on the nature of your concerns.

We will keep your complaint on record to help us identify patterns of provider practice, complaint trends, or systemic issues.

Access to records / Access to health records

(You are required to tick at least one of the items below)

Please select below to confirm you are making a complaint about a health service provided to you
I am complaining about the service/treatment provided to me and I understand the Office of the Health Ombudsman may need to access my personal health information for the purpose of handling this complaint. Access to this information will be in accordance with the Act.

Enter your name

(Required)

Date

(Required)

Open the calendar popup.

Please select below to confirm you are making a complaint about a health service on behalf of someone else
I am complaining about the service/treatment provided to the consumer and I understand the Office of the Health Ombudsman may need to access their personal health information for the purpose of handling this complaint. Access to, and disclosure of this information will be in accordance with the Act.

I am the parent/appointed guardian of the person who received the service/treatment.

I am complaining about the service / treatment provided to a person who has died.

The consumer has asked me to make the complaint.

Enter consumer name

(Required)

Enter your name

(Required)

Date

(Required)

Open the calendar popup.

Before you send this form, please check that you have:

included as much relevant information as possible
given details of the health service provider you are complaining about
clearly identified your concerns
consented to us accessing your healthcare information
attached copies of supporting documents or information—please do not send original documents.

Privacy and confidentiality

In managing your complaint, we collect personal information about you.

We comply with the Information Privacy Principles in the Information Privacy Act 2009.

We are required to provide your complaint to the person and/or organisation you have named. If there is any information you don't want them to receive, please let us know

If your complaint is about a registered practitioner, we will advise the Australian Health Practitioner Regulation Agency of your complaint.

We will not disclose your personal information to anyone else unless you consent or the disclosure is allowed, authorised or required by law.

You can apply to access or amend documents held by us under the Information Privacy Act 2009 and the Right to Information Act 2009. Some documents - for example those containing the personal information of other people - may be exempt from access.

It is an offence for a person to provide false or misleading information to the Office of the Health Ombudsman

Make a complaint

Use this form to make a complaint.

Your Details

Details of the person you are complaining on behalf of

Who is this complaint about?

Health service provider 1:

Health service provider 2:

How have you tried to resolve this complaint?

Your Complaint

Access to records / Access to health records