oklahoma state department of health office of accountability systems

OKLAHOMA STATE DEPARTMENT OF HEALTH

OFFICE OF ACCOUNTABILITY SYSTEMS

(“OAS”)

COMPLAINT FORM

Oklahoma State Department of Health ODH No.130 (Rev. 8/2013)

Office of Accountability Systems

Please fill out all of the fields below to expedite the complaint process.

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Person Making Complaint:

Do you want your identity to remain confidential? _______ Yes _______ No

Without sufficient information we may be unable to act upon your allegation. Providing us with

as much information as possible will assist us in making a determination regarding whether any

wrongdoing may have been committed.

Name: _______________________________________________________________________

Email: _______________________________________________________________________

Mailing Address: ______________________________________________________________

______________________________________________________________

City/State: ________________________________________________Zip Code____________

Phone number: (________) ________ -____________ Home _____ Office ______ Cell ______

Preferred Method of Contact: ______________________________

Failure to provide the above information may prevent a full and complete investigation if any

questions arise during the course of the investigation.

REASON FOR COMPLAINT:

(Be specific as to the reason you are filing the complaint and include specific facts, names, dates, places,

etc.)

______________________________________________________________________________

Please use the back of this sheet or attach additional sheets, if necessary.

PLEASE NOTE: For complaints/questions in medical scope operations regarding medical doctors,

contact the State Board of Medical Licensure and Supervision (405) 962-1400 or (800) 381-4519, for

osteopathic doctors, contact the State Board of Osteopathic Examiners at (405) 528-8625, or for nurses,

contact the Oklahoma Board of Nursing at (405) 962-1800.

OKLAHOMA STATE DEPARTMENT OF HEALTH

OFFICE OF ACCOUNTABILITY SYSTEMS

(“OAS”)

COMPLAINT FORM

Oklahoma State Department of Health ODH No.130 (Rev. 8/2013)

Office of Accountability Systems

INSTRUCTIONS

The purpose of the Oklahoma State Department of Health (“OSDH”) Office of Accountability

Systems (“OAS”) complaint policy and this complaint form is to provide a process for OSDH

employees, OSDH service recipients or members of the general public to submit complaints if

they suspect fraud, waste, abuse, mismanagement, or misconduct by this Agency, its

contractors/agents, or any of its employee(s). This complaint process is also intended to

respond to the Agency’s potential failure to follow its established policies and procedures, and

unlawful retaliatory disciplinary action against an OSDH employee for engaging in protected

whistleblower activity under the Oklahoma “Whistleblower Act” set forth at 74 O.S. § 840-2.5.

This procedure is not intended to bypass any policy or procedure contained in the OSDH

Administrative Procedures Manual, for example, OSDH Policy 6-23 Employee Grievance

Procedure.

To submit an Office of Accountability Systems complaint to OSDH, please use one of the

following options:

OAS Mailing Address:

Oklahoma State Department of Health

Office of Accountability Systems

123 Robert S. Kerr, Room 1702

Oklahoma City, OK 73102-6406

OAS Telephone & Email:

OAS Hotline: 1-866-271-7211

OAS@health.ok.gov

Option 1 (Plain text format)

Go to our website at www.ok.gov/health. Open the link to the Office of Accountability

Systems. Open the “Complaint Form” link in the body of the text. Print the form.

Complete the form and either mail it to the OAS mailing address, Email to

[email protected], or hand-deliver it to the OAS office located at Oklahoma State

Department of Health, 123 Robert S. Kerr, Oklahoma City, Oklahoma 73102-6406.

Option 2 (Hard copy format)

Obtain a hard copy complaint form from your local county health department or from the

OSDH central office located at 123 Robert S. Kerr, Oklahoma City, Oklahoma 73102-6406.

Complete the form and either mail it to the OAS mailing address, Email to

[email protected], or hand-deliver it to the OAS office of the OSDH central office (see

above).