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IAC Complaint Form

The IAC investigates complaints that identify specific noncompliance to the IAC Division Standards and/or the IAC Accreditation Program Policies and Procedures.

Items with * are required.

DR. MR. MRS. MS.

FIRST NAME:

LAST NAME:

TITLE:
(i.e., RDCS, MD)

STREET ADDRESS:

CITY:

STATE:

ZIP/POSTAL CODE:

PHONE:

 

E-MAIL:

*DO YOU WISH TO REMAIN ANONYMOUS?: *Required
Yes
No
Please select one only.

*RELATION TO COMPLAINT (select one only): *Required
Employee
Former Employee
Employee of Another Facility
Patient
Relative of Patient
Consumer
Please select one only.


*THIS IS A (select one only): *Required
Accredited Facility
Non-Accredited Facility
Other Organization/Business
Please select one only.

*FACILITY NAME:

*Required

STREET ADDRESS:

CITY:

STATE:

ZIP/POSTAL CODE:

PHONE:

 

WEBSITE ADDRESS:

*NATURE OF COMPLAINT (select one only): *Required
Accredited Facility Non-Compliance to IAC Division Standards and/or Accreditation Policies and Procedures
Misrepresentation of Accredited Status
Misrepresentation of IAC Endorsement
Other Fraud
Please select one only.

*Provide specific details regarding the alleged complaint including name any persons involved, dates, times:

*Required

Attach any supporting documentation in the box below. Remove any patient-related personal information from documents unless the complaint is being submitted by or on behalf of the patient.

Please select an item.

*HAVE YOU CONTACTED ANY OF THE FOLLOWING IN RELATION TO THIS COMPLAINT? (select one only):
*Required
Any Other Accrediting Agency (if yes, specify):
Any Employees or Representatives of the Facility (if yes, specify):
Any Local, State or Federal Agencies (if yes, specify):
Other:
No, I have not contacted anyone regarding this complaint
Please select one only.

*Date Complaint Submitted: *Required (i.e., 01/01/2017)

*By checking this box, I declare, under penalty of perjury, that the information in this complaint is true and complete to the best of my knowledge.
*Required: You cannot submit the form until you accept the terms and conditions.



Intersocietal Accreditation Commission
6021 University Boulevard, Suite 500, Ellicott City, MD 21043
phone 800-838
-2110 | fax 866-663-5663
web intersocietal.org

 

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