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IAC Form for Complaints Against the IAC
Complaints against the IAC must be reported using the form below for submitting a complaint against the IAC. The IAC will acknowledge your complaint submission and contact the complainant as warranted.

Items with * are required.

FIRST NAME:

LAST NAME:

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

PHONE:

(i.e., 555-555-5555)

*E-MAIL:

*I AM (select one only): *Required
Employee of Currently Accredited Facility
Employee of a Facility Seeking Accreditation
Potential Customer
Vendor
Consumer
Please select one only.


*NATURE OF COMPLAINT (select one only): *Required
Accreditation Process
Customer Service
Other
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
Yes, any members of the IAC staff (i.e., Supervisor):
Yes, any other IAC department (i.e., Compliance):
Other:
No, I have not contacted anyone regarding this complaint
Please select one only.

*Date Complaint Submitted: *Required (i.e., 01/01/2016)

*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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