GRIEVANCE REGARDING LACK OF HEALTH CARE ACCESS BASED ON DISABILITY


First Name
Last Name
Address
City
State
Zip Code
Phone Number
Email Address
Date of Birth
Date of Incident
Purpose of Service for Request (visit to heart doctor; MRI)
SC Facility or Health Care Provider (if known)
Witnesses (Other than SC employees)
Name of Third Party Submitting Grievance (if applicable)
Third Party Requester Type:

Third Party Requester's Phone Number
Was an accommodation requested prior to the incident?
If yes, what type of accommodation was requested? (Be specific - e.g., transfer with electronic lift, interpreter services for deaf, bariatric MRI equipment)
Reason for Grievance (Provide a specific account of incident)