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Complaints Form
The following form may be used to submit complaints to SMHCEMS Administration.
Alternatively, you may submit complaints to the
Texas Department of State Health Services
.
Name of person making complaint:
Required
Mailing Address of person making complaint:
City, State, Zip of person making complaint:
Phone number of person making complaint:
Required
Your relationship to subject of complaint (Patient being treated, Family of Patient, Bystander etc):
Required
Date and Time of Incident
Required
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Email address of complaintant:
Please type the letters and numbers shown in the image. Click the image to see another captcha.
Submit