Print this Page Tim Testing Patient medical record access request Today's Date* Your Information Note: Providing contact information allows UMC Health System to contact you about actions taken in regard to your complaint, or allows us to contact you if more information about your complaint is needed. Name* Address Address 2 City Zip Code Email Phone* Format: (000) 123-4567 Complaint Information Date(s) of hospital care related to complaint* Start Date End Date Location in hospital related to complaint* - Select - 3 East 3 West 4 East 4 West 5 West Accounts Recovery Administration Admissions Biomedical Burn Services Cafeteria Case Management Cath Lab Cath Lab Per-op Construction Management Corporate Compliance Corporate marketing CVICU/CICU Day surgery Decision Support Education Resources Emergency Center Emergency Center Physicians Emergency Medical Services Endoscopy Center Environmental Services Family Birth Center Family Care Unit Food & Nutrition Foundation General laboratory Administration Geriatric Trauma Unit Grand Expectations Health Information Management Healthplan Operations Hemodialysis Home Health Human Resources ICCU Infection Prevention & Control IT Analytics IT Clinical Informatics IT Infrastructure Medical Intensive Care Unit Neonatal Intensive Care Unit Northstar Therapy Nurse Recruitment Nursing Support Services Operating Room Outpatient Surgery Pastoral Care Patient Accounting—coll. Patient Placement Center Pediatric Intensive Care Unit Pediatrics Performance Improvement Respiratory Therapy Revenue Integrity Safety Services Security Seniors are Special Service Development Social Services STAR Center Supportive Care Unit SWCC Administration SWCC Chemotherapy Telephone Triage Transplant Services Trauma & Burn Service Trauma and Surgical ICU TTUHSC Utilities Management Volunteers Who are you filing complaint on behalf of* Self Family Member Other... Please give us information on this person Name* DOB* Phone* Format: (000) 123-4567 Desired Outcome Apology Bill Waived Call back from UMC leadership Change Attending Physician Change in Process/Procedure Clarification/Explanation Commendation Corrective/Disciplinary Action Improved Care for Patient/Others Item Recovered/Replaced Nothing Specific Notification of Staff Physician Contact Reimbursement Report to Outside Agency Transfer to Other Room/Unit/Facility Description Please provide a description of your complaint. Describe the action(s) that lead to filing a complaint and the individuals involved* Supporting Documentation Upload supporting documentation below, if applicable. Supporting Document This field is required If you uploaded supporting documentation please be patient while the form is submitting. You will see a confirmation message when the process is complete. Submit