LTC Ombudsman Program Inquiry/Complaint Form

We welcome your questions or comments. Please use the form below to contact us. If you would like a reply, enter your name, address (postal or e-mail), and/or phone number. Do not submit personal information such as Social Security numbers or detailed medical history; if we need additional information, we will be in touch with you.

The LTC Ombudsman Program may also be contacted by calling (888) 282-1155 (toll free).

Please fill out the information below as it relates to your question or concern.

Your Name: 

E-mail: 

Telephone Number: 

 Type of Contact: Please Choose One General LTC Question LTC Facility/Resident Concern Other

Name of Resident, if Different: 

Your Relationship to the Resident: Please Choose One Self Spouse Child Grandchild Parent Sibling Other Relative Friend Other

Name of Facility: 

Location of Facility:   

Question or Concern:     

Vulnerable Adult Abuse is NOT to be reported through this form. Click on Report Vulnerable Adult Abuse or contact the Regional Office for more information.