ཁྱིམ / ཉོགས་བཤད་དང་ མཐོ་གཏུགས། ཉོགས་བཤད་དང་ མཐོ་གཏུགས། Complaint Form Complaint Form * field must be filled in Your Name * Your Relationship to the Member SelfParentFamily MemberGuardianFriendOther Your Relationship to the Member Your Contact Phone Number * Do you have a completed Designated Client Representative Form (DCR)? * Yes No This form is required for you to file a complaint on behalf of a Member 15 or older. Member's Name * Member's Medicaid Number Member's Date of Birth * Who is your complaint against? What is your complaint? * What is the outcome you would like? Submit