Review Request

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

First nameMissing or incorrect value

Last nameMissing or incorrect value

Date of birth

Missing or incorrect value

Personal Health Number (PHN)Missing or incorrect value

Primary phone number Missing or incorrect value

Email addressMissing or incorrect value

Address 1Missing or incorrect value

Address 2

CityMissing or incorrect value

Province Missing or incorrect value

Postal codeMissing or incorrect valueFormat as A1A 1A1

Date of Care/Service

Missing or incorrect value

Where or in which facility (e.g., hospital) did the incident(s) occur?Missing or incorrect value

What is the nature/description of the complaintMissing or incorrect valuei.e., what happened

Date Complaint Filed With PCQO

Missing or incorrect value

What was the Patient Care Quality's Office's response to the complaint? (If you received a written response, please attach a copy.)Missing or incorrect value

Attach a copy of the response (if available)

Drag files here or use the button below. Remove File

Select File

What is the reason you are not satisfied with the Patient Care Quality Office's response to the complaint?Missing or incorrect value

What outcome or resolution are you seeking through the review process?Missing or incorrect value

Have you registered the complaint with another agency?Missing or incorrect valuee.g., the College of Physicians of BC or the Ombudsperson

Please provide any additional information you would like the review board to consider.

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 use the button below. Remove File

Select Files

Where did you hear about us?Missing or incorrect value

Email addressEnter 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

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.

HLTH 8107-2040 2023/03/15

Review Request

Information for Individual Who Received the Care or Service

Authorization

Consent and Affirmation

Keep a Copy for Your Records (optional)

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