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Office of Health Facility
Licensure & Certification

COMPLAINT FORM


COMPLETE THIS FORM AND RETURN TO:
Office of Health Facility Licensure & Certification
408 Leon Sullivan Way
Charleston, WV 25301-1713
(304) 558-0050

LOG NUMBER  

DATE  

OFFICIAL USE ONLY
NOTE: Fill out this form to the best of your ability for the Office of Health Facility Licensure & Certification to address your concerns. Without sufficient information, an investigation may not be feasible. Be sure to include as much detail as possible
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Facility Information
Complainant Information
If you wish to be anonymous, you will not receive any notification on the status or results of the investigation.
You may be contacted by our office for more information.
Affected Patient, Resident, or Consumer Information
Preliminary Action
Complaint Information