If You Have a Concern

We take each patient concern within our group seriously. Below, please describe in detail the incident in question so that our Medical Compliance Officer can address it with the appropriate personnel and/or provider.

It is our goal to respond to a concern within 48 hours of receiving it.

Important note: This form is intended for Providence Medical Group, Dayton, Ohio medical practices only.

Providence Medical Group employees —
If you have a concern you’d like to address, please report it to the Human Resources department in person, or to Jamie Gibson at jgibson@provmedgroup.com.
Do not use the form below, you will not receive a response.

Providence Medical Group — Dayton
Complaint Form

 

Information About You

Please provide a number where you can be reached


Provider


Complaint

Please describe your complaint as completely as you can. Please date the form.