Concerns & Compliments

PATIENTS & VISITORS

Ensuring you have a positive healthcare experience while you are a patient or visitor at The Richland Hospital and Clinics (TRHC) is very important to us. Should you have a concern regarding your patient experience, please let any of our employees know and we will make every reasonable effort to resolve your concern immediately. We would also appreciate any feedback on what we are doing well and what parts of your patient experience were positive.

It is your right as a patient or family member to complete our Patient Concern/Compliment Form below regarding any part of your patient care experience. Communicating a concern or comment will in no way compromise your future care at TRHC. In fact, it may improve future experiences for yourself and other patients. It is our goal to improve care to meet patients’ needs whenever possible.

Your concerns are important to us

Grievances can be communicated to us online or by mail. Please complete the electronic form below, or download a PDF, print, complete, and mail to The Richland Hospital and Clinics, Community Relations, 333 East Second Street, Richland Center, WI 53581.

After your concerns are made known, they will be reviewed by TRHC management and administration. We will respond within 30 days.

Patient Concern/Compliment Form

Patient Name

Date of Birth

Street Address Line 1

Street Address Line 2

City

State

Zip

Email Address

Preferred Phone

Department

Physician

Clinic

Dates of Service

Concern/Compliment

If you have a concern, have you spoken to anyone at the hospital or clinic about it? If you have a concern, have you spoken to anyone at the hospital or clinic about it? Yes No

If yes, who did you speak with?

Date

Signature

Additional Options

If you feel that you would like to take your formal grievance to the next level, the following are your options:

The State of Wisconsin Bureau of Quality Assurance
PO Box 2969
Madison, WI 53701-2969
Phone: 1.800.642.6552

or

DNV Healthcare USA Inc.
Attn: Healthcare Complaints
4435 Aicholtz Rd.
Ste. 900
Cincinnati, OH 45245
Phone: 1.866.496.9647
hospitalcomplaint@dnv.com

On behalf of The Richland Hospital, thank you for trusting us with your care.

SHARE YOUR EXPERIENCE

PATIENTS & VISITORS

PATIENTS & VISITORS

CONCERNS & COMPLIMENTS

Your concerns are important to us

Additional Options