Review Request

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For people who have submitted concerns to their health authority's Patient Care Quality Office and were not satisfied with how the concerns were handled or the response they received. Use this form to request that the Patient Care Quality Review Board look into the matter.

The Patient Care Quality Review Boards have legal authority to review a care quality complaint that has been addressed by a health authority's Patient Care Quality Office but remains unresolved. If you have not submitted this complaint to a Patient Care Quality Office, you should complete that process before submitting a review request form. For more information, please visit www.patientcarequalityreviewboard.ca
 
Note: Depending on your computer’s settings, there is a small chance your internet browser might reload and lose your changes if this form is left open for too long. If you think it will take you more than 30 minutes to fill in the details of your complaint and your desired outcome, please consider writing up your answers in a Word document to ensure they are saved. You can then copy-paste the answers into this form or attach your Word document.
 
If you need assistance completing this form, please call 1 866 952-2448.
 

Information for Individual Who Received the Care or Service

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Date of birth Missing or incorrect value
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555-555-5555 Missing or incorrect value
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Missing or incorrect valueFormat as A1A 1A1

Date of Care/Service Missing or incorrect value
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Missing or incorrect valuei.e., what happened

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Date Complaint Filed With PCQO Missing or incorrect value
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Attach a copy of the response (if available)
Drag file here or select file.
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Missing or incorrect valuee.g., the College of Physicians of BC or the Ombudsperson

If you have any other supporting documents that you wish to include with this submission, please do so by clicking on the "browse" button and locating the file on your computer.
Drag files here or select files.
Remove File
Missing or incorrect value
Enter if you would like us to communicate with you through email.

Authorization

The personal information requested on this form and any additional information required by a Patient Care Quality Review Board in reviewing the care quality complaint submitted by or on behalf of an individual is collected under the authority of the Patient Care Quality Review Board Act and the Freedom of Information and Protection of Privacy Act, and will be used only for the purpose of reviewing this complaint. All persons obtaining personal information under the Patient Care Quality Review Board Act are under a duty of confidentiality with respect to that information. If you have any questions about the collection, use or disclosure of this information please contact the Patient Care Quality Review Board Secretariat at the telephone number, fax number or mailing address set out at the bottom of this form. The authorization you complete below becomes effective on the date this form is submitted and remains in effect until the review is completed.

Consent and Affirmation

Please make the applicable selection below:Missing or incorrect value

Keep a Copy for Your Records (optional)

To protect your personal information from third parties, we will not send you a copy of this form by email. If you want to keep a copy for your records, you can download a copy using the PDF button below. After you submit the form, a confirmation email will be sent to you. 
HLTH 8107-2040 2024/09/26
11abac5ae987675c87c2f07fd60918fc95767acf
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