Online Complaint Form

Contact Information

Name (required):

Provider (if applicable):

Address (required):

Apartment or Suite Number:

City (required):

State (required):
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP Code (required):

Preferred Phone Number (required):

Work Phone Number (optional):

Your Email (required):

Complaint Information

My Compliant Concerns (you may check more than one; required):
Access to AssistanceAccess to InformationAccuracy of InformationCommunicationDissemination of InformationProcedure/ProcessResponsivenessService DeliveryService QualityStaff ExpertiseTimeliness/PromptnessWait Times

My Complaint Is (required):

What do you consider a resolution to your problem (required):

By checking the box below, I understand that the information submitted on this form (except for my email address) is subject to disclosure under the Texas Public Information Act.
I understand

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