Complaint or Concern Form

The purpose of this form is to provide a method to file a concern or complaint regarding EMS care in Oakland County. If you have a complaint or concern you would like to submit for the MCA to review, please complete the entire form with as much information that can be provided. If available, please provide the patient care record.
* Required Field
Name of Agency involved with the concern or complaint:*
Name of Provider(s) involved with the concern or complaint, if available or applicable (if Unknown or N/A, please list as such):*
Agency incident number of the concern or complaint, if available or applicable (if Unknown or N/A, please list as such):*
Date of the incident that created the concern or complaint::*
Time of the concern or complaint:*
Please describe the complaint with as much detail as possible:*
Please note:
No concern or complaint will be accepted unless the person reporting provides their name and contact information. The OCMCA staff may need to contact the reporter to ask clarifying questions. The reporter has the right to request anonymity. If anonymity is requested the OCMCA staff will not share that information with any other persons or meeting groups.
Reporter name:*
Reporter email or phone number:*
Are you requesting anonymity?*
- Yes
- No
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