Healthcare Service Provider

Complaint Form
Please Note

By filing this complaint you are authorizing the Commission to have complete access to
all the record relevant to the matter.

Instructions

Please fill out the form completely. Also submit a duly notarized affidavit, according to
sample format attached to this form.

If you need assistance to fill in the form or require any information, please call the PHC
Helpline 0800 00742 (toll free).

Details of the Healthcare Establishment

Name of the concerned HCE: _____________________________

Name of the In-charge of the concerned HCE: ________________________________

Address of the concerned HCE: ___________________________________________

District:_________________ Tehsil: ________________ Postal Code: _____________

Mobile No: ____________________ Telephone No: ____________________________

Fax: _________________________ Email Address: ____________________________

Details of the Complainant

Name________________ ___________________ _____________________

(First) (Middle) (Last)

Your designation at the concerned HCE: ____________________________________

CNIC No: ___________________ Address___________________________________

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District:_________________ Tehsil: ________________ Postal Code: _____________

Mobile No: ____________________ Telephone No: ____________________________

Healthcare Service Provider Complaint Form - Punjab Healthcare Commission
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 Healthcare Service Provider
Complaint Form
Fax: _________________________ Email Address: ____________________________

Nature of your complaint

Harassment Damage to HCE Other (Please specify): _________________

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Write your Complaint

Use the space below to write your complaint. Please include persons who were
involved, what happened and when. Please attach a separate page if you want to give
us more details.

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Name and details of the concerned patient/client? (If involved in the incident)

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Healthcare Service Provider Complaint Form - Punjab Healthcare Commission

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 Healthcare Service Provider
Complaint Form
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Mention the names of the persons suspected to be involved and their relationship with
the concerned patient/client?

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Please mention the date of the incidence?

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What is your specific request to the Commission?

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Did you make a complaint to any other organization about the same matter? If yes,
mention the date on which you made the complaint and its result? Please attach
relevant documents if any.

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Attach copies of these documents with your complaint

Affidavit
Original copy of authorization letter duly authenticated by the concerned HCE
in support of your complaint
Copy of your CNIC or any other document depicting your identity;
Other relevant documents in support of the complaint.

Please send your complaint and supporting material to this address

Punjab Healthcare Commission

Healthcare Service Provider Complaint Form - Punjab Healthcare Commission
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 Healthcare Service Provider
Complaint Form
Office #1&2, 4th Floor, Shaheen Complex
38, Abbot Road Lahore
Fax: 042-36376370
Email: complaints@phc.org.pk

Privacy Statement
The Commission will not disclose any information provided by you other than in carrying
out its functions under the Punjab Healthcare Commission Act, 2010.

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Date

Healthcare Service Provider Complaint Form - Punjab Healthcare Commission

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 Sample Format for Affidavit
(Produce the following content on a duly notarized stamp paper)

AFFIDAVIT OF ____________________
S/o or as the case may be
R/o
(Please mention the capacity in which you are submitting
this affidavit on behalf of the Healthcare Establishment)

I solemnly affirm and declare as hereunder:

1. Mention the contents of your complaint

2. That the allegations contained in the complaint are true and

correct to the best of my knowledge and belief.

3. That no suit, appeal, or any other proceedings in connection with the

subject matter of the complaint are pending before any court of
competent jurisdiction;

4. That no allegation contained in the complaint is without reasonable

and justifiable ground(s) and that it is not being made simply
with an intention to harass, defame, embarrass and/or to
pressurize the party complained against.

5. That I fully understand that in case my complaint is proved to be false,

then I shall be liable to pay fine, which may extend to Rupees Two
Hundred Thousand.

6. That I undertake to keep the Commission informed of my address and

contact details and I further undertake that I shall regularly attend the
hearings on the dates fixed by the Commission and fully understand that
if I fail to attend the same for no sufficient
reason despite three consecutive notices, or wilfully delay the
proceedings of the Commission in its opinion, then I shall be
liable to pay the costs as awarded by the Commission and that
 the Commission shall decide the complaint as per the
governing law.

7. That I have not filed a complaint on the same subject matter

before the Commission nor the same matter is already pending
before the Commission and further that the subject matter has
not already been decided by any forum.

DEPONENT

Verification: -

Verified on oath at _____________ on this ___ day of ____ 2013 that the
contents of the above Para No. ____ to Para No. ____ are true and correct to the
best of my knowledge and belief and those of Para No. ____ to _____ are
correct as per the information provided to me and that nothing has been
concealed therefrom.

DEPONENT

OR IF THE INFOMRATION IS BASED ON SELF KNOWLEDGE AND

BELIEF THEN: -

DEPONENT
Verification:-
Verified on oath at _____________ on this ___ day of ____ 2013 that the
contents of the above affidavit are true and correct to the best of my knowledge
belief and that nothing has been concealed therefrom.

DEPONENT