Feedback

To give feedback on a CHQI Accredited Organization,
complete the form below.
First Name:
Last Name:
Phone: *
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Accredited Org Name:
Accredited Org State:
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Incident Date: *
I have read the disclaimer and would like to submit my claim.

To provide feedback for CHQI, complete the form below.
First Name: *
Last Name: *
Phone: *
Email Address: *
Address 1:
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Please choose the type of feedback you will be providing: *
Disclaimer:
***DO NOT submit protected health information (PHI) on this website. PHI is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual. Submitting PHI to CHQI is strictly prohibited. Should CHQI receive PHI, the Complainant will be contacted with a request to re-submit the complaint with PHI removed.***