Examples

Pick one of the letters and call sheets goyo writes.

Example

Appeal the discharge: the second review

After the Medicare review office said no, a call sheet for the second reviewer.

Second reviewerPhone call
Your call sheet

Ask for a second review

Patient: Elena Marsh
Date of birth: 12 May 1941
Review office answer: 14 March 2026

Say this first

"I am calling to ask for a fast second review of the decision made on 14 March 2026 for Elena Marsh, born 12 May 1941, at Harbor Point Medical Center. I disagree with that decision. I have new information."

Do not forget
  • Ask them to confirm the request is open as of today's date and time.
  • Write down the time, the name and the case number.
  • If they ask for it in writing, send the short request in your letters.
Second reviewerLetter

Re: Request for a second review

Patient: Elena Marsh
Date of birth: 12 May 1941

I ask for a second review of the decision of 14 March 2026. The new facts are:

  1. Call the second reviewer, and your call sheet has the words.
  2. Send the short letter if they ask for it.
  3. Attach the review office decision and any new letter from the doctor.
Time to askBy noon the day after the review office told you (42 CFR 405.1204)
The office answersWithin 72 hours of getting the request and the records (42 CFR 405.1204)
Example

Report a care or safety problem: the state health office

After the hospital did not settle it, a letter to the state health office.

State health officeLetter

Re: Complaint to the state health office

Patient: Elena Marsh
Date of birth: 12 May 1941
Place: Harbor Point Medical Center

I ask you to look into Harbor Point Medical Center, which I told about this on 20 March 2026. What happened:

  1. Send it to your state health office.
  2. Attach the hospital's answer, if you have one.
  3. Ask the Medicare review office too, if you want a written finding.
Time to askNo filing deadline, so file soon.
The office answersThe office sets its own timing
Example

Correct the record: add your statement

After the records office said no, a statement of disagreement for the record.

Records officeLetter

Re: My statement of disagreement

Patient: Elena Marsh
Date of birth: 12 May 1941

I disagree with your refusal of 2 June 2026 to correct my record. The entry is the nursing note of 12 March 2026. Why I disagree:

  1. Write your side in your own words.
  2. Ask that it goes with the record every time it is shared.
  3. Complain to the privacy office and the Office for Civil Rights if they do not follow the rule.
Time to askNo set number of days for the statement (45 CFR 164.526)
The office answersThey must add it to the record. They may reply and send you a copy (45 CFR 164.526).

Some offices use their own form

Each box has a limit, and your story will fit.

See the forms
Example

Florida: complaint about a hospital or nursing home

Florida Agency for Health Care Administration, online form.

Name of the health care facilitylimit 200 characters
Harbor Point Medical Center
27 of 200 characters
Patient or resident's namelimit 255 characters
Elena Marsh
11 of 255 characters
Narrativelimit 4,000 characters
My mother, Elena Marsh, 84, had surgery for a broken hip at Harbor Point Medical Center. On 14 March 2026 we were told she would go home that evening. Her therapist's note that morning said she could not yet walk safely with a walker and needed a rehab stay. We were given no written discharge notice and no one explained how to appeal. She left at 9 pm with no walker, no home therapy plan and no list of her new medicines. She fell at home the next morning. I am asking you to review how this discharge was decided and whether the hospital followed its discharge planning rules.
580 of 4,000 characters

The form says you may upload a file if you need more room.

Example

Hospital accreditor: complaint about a hospital

CIHQ, online form.

Incident locationlimit 48 characters
4 West discharge desk
21 of 48 characters
Name of patientlimit 48 characters
Elena Marsh
11 of 48 characters
Incident descriptionlimit 6,000 characters
My mother, Elena Marsh, 84, had surgery for a broken hip at Harbor Point Medical Center. On 14 March 2026 we were told she would go home that evening. Her therapist's note that morning said she could not yet walk safely with a walker and needed a rehab stay. We were given no written discharge notice and no one explained how to appeal. She left at 9 pm with no walker, no home therapy plan and no list of her new medicines. She fell at home the next morning. I am asking you to review how this discharge was decided and whether the hospital followed its discharge planning rules.
580 of 6,000 characters
Example

New York: complaint about a nursing home

New York State Department of Health, online form.

Room numberlimit 255 characters
214
3 of 255 characters
Description of the complaintlimit 1,000 words
On 2 March 2026 at about 6 am my father, Tomas Reyes, fell in the hallway of the second floor. Staff helped him up and put him back in bed. No doctor was called for five hours. He kept saying his left hip hurt. An X-ray that afternoon showed a broken hip. The nurse on the night shift told me the fall was not written in his chart until the next day. I want to know why the doctor was not called, and why the fall was written late. I can give the names of the two aides who were with him.
102 of 1,000 words

This form counts words, not characters.

Example

Illinois: complaint about a healthcare facility

Illinois Department of Public Health, fillable PDF.

Describe what actually occurredno limit printed
Who: Elena Marsh, 84, patient on 4 West.
What: sent home the evening of surgery with no walker, no therapy plan and no medicine list.
When: 14 March 2026, about 9 pm.
Where: Harbor Point Medical Center, 4 West discharge desk.
Harm: she fell at home the next morning.
Five short lines, since the form asks for facts: who, what, when, where.

For other problems, see Who has to answer.

Upload your medical documentation