Health Systems Quality Assurance Complaint Intake Form
Instructions

Select the "Begin Complaint Process" button at the bottom of this page to begin your report.

Please read the frequently asked questions (FAQs) before completing the form. Please use this form to file a complaint against an individual healthcare provider, healthcare facility, to self-report an incident, or report the unlicensed practice of a healthcare profession or facility. The healthcare provider or facility must be credentialed by the Washington State Department of Health, or practicing healthcare within Washington State without a license.

You can look up a provider or facility credential on our provider credential search and license verification webpage. If you need assistance completing this form or would prefer a PDF or Microsoft Word version of the form, contact us at 360-236-2620 or by email. If you submit your complaint through this web form, please do not submit multiple copies of your complaint by mail, email or fax.

Contact the Health Systems Quality Assurance (HSQA) Customer Service Center at 360-236-4700 or by email with other questions such as:

  • Questions about laws, rules, or scope of practice for a profession or facility.
  • Licensure, status of application, or renewal of license.
  • Requesting copies of complaint files or Department of Health records related to a healthcare professional or facility.

Public disclosure statement: The Department of Health is required by law to release copies of this complaint form and/or any other documentation you submit in regards to this report upon receiving a public disclosure request. This includes releasing copies to the person you identified in the complaint/report. In compliance with the public records act the departments may redact and withhold certain information.