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About
Our Providers & Staff
Our Contract Partners
What’s New at MWI Health
Services
Forensic Psychiatry / Veteran’s Comp & Pension Evals
Telepsychiatry & Medication Management
Suboxone & Naltrexone
Spravato
TMS
Youth Services Grievance
TMS
Patient Registration
Patient Registration
Payment Options
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605.573.2000 (M-F, 8:30am - 4:30pm)
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MWI Health - Midwest Wellness Institute
Submit online form below or click below to print and mail to address below.
Click here for Quality of Care Complaint .pdf form to download
Submit A Quality of Care Complaint
Please provide as much information as possible to assist in determining what steps need to be taken. If you would prefer to talk to someone about this information, please call the MWI Grievance Monitor at 605-573-2000 Monday through Friday between 8:00 to 5:00. If after hours, on a weekend or a holiday, please leave a voice message with your contact information. If this is a concern of child abuse or neglect, please call the Child Protection Services Intake Toll Free at 1-877-244-0864 Monday through Friday between 8:00 to 5:00. If after hours, on a weekend or a holiday, call 911.
Please enable JavaScript in your browser to complete this form.
List the name of the facility/shelter provider or the name of the person you have a concern with:
*
List the address or city of the facility/shelter provider (if unknown, describe approximate location):
*
If known, list the telephone number of the facility/shelter:
When did this concern occur? If you know the date, please enter MM/DD/YY
*
Describe what happened (see below for details that should be included): NOTE: The grievance monitor must have enough details about the situation to determine intervention next steps. When providing details about your concern, think in terms of sharing. WHO-- Who is involved (name of program, staff person, or names of child or children, etc.)
*
WHAT-- What happened to you, a child or children; be specific about what occurred.
*
WHERE-- Where did this happen (at the facility, a park, in what specific classroom, bedroom, bathroom, etc.)
*
WHEN-- When did this happen (date, time of day, during class or lunch time, etc.) -- Was this the first time it happened? If not, how many times has this happened? How long has it been happening?
*
HOW-- Describe in detail how it happened and how you found out about this issue if it happened to someone other than yourself.
*
Did you report your concern to any other person?
*
Yes
No
If yes, who did you report it to?
Facility/Program Staff
Administrator
Case Manager
Local Police
Child Protection Services
Family Service Specialist (FSS)
Juvenile Correction Agent (JCA)
Parent / Family Member / Guardian
Other - if you have reported it to someone else, please state their name below.
If reported to more than one person, please provide each person's name below.
If you reported it to someone, what is their name (first & last)? What is their phone number?
Where (what city) is the person you reported to located?
*
When did you report your concern? (MM/DD/YY)
*
How did you report your concern?
*
In Person (face to face)
Phone Call
In Writing (email or letter)
Other
If you have selected other, please specify below.
Other:
How do you know the facility/shelter provider involved in your concern?
*
I am a current resident of the facility/shelter program
I am a former resident of the facility/shelter program
I am a current employee of the facility/shelter
I am a previous employee of the facility/shelter
Facility/shelter provides care for my child
Facility/shelter provides care for a friend or relative of mine
I am a Mandated Reporter/Professional
I don't know the provider, I witnessed this incident
Other
If you have selected other, please explain below.
Other:
How often do you have contact with this facility/shelter?
*
Daily
Weekly
Monthly
Never
Is there anyone else who might have knowledge of this concern that we should contact?
*
Yes
No
If yes, what is the person's name?
First
Last
If yes, what is the person's phone number? (If you know it.)
Your name:
First
Last
Taking the time to tell us your concerns is very much appreciated. The name of the person making a complaint is not provided to the facility/shelter when addressing the complaint. If the facility/shelter attempts to guess who made a complaint, the grievance monitor will not confirm or deny who made the complaint. If there is not enough information provided on this complaint form, we may not be able to address your concerns. For purposes of obtaining more information or clarifying the details you have submitted, please list your contact information below:
Your phone number:
Your email address:
Submit
If you prefer to print and mail your complaint, click below, print, and mail to:
MWI Health
Attn: Grievance Monitor
4308 S Arway Dr
Sioux Falls, SD 57106
Click here for Quality of Care Complaint .pdf form to download
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