Document text
Request for Review of an HCCC Assessment Decision
[YOUR FULL NAME]
[YOUR ADDRESS]
[EMAIL] · [PHONE]
Health Care Complaints Commission
[ADDRESS OR EMAIL FROM YOUR DECISION LETTER]
[DATE]
Sent by: [EMAIL TO … / POST, POSTAGE RECEIPT …]
Dear [ASSESSMENT OFFICER'S NAME],
Request for review of the assessment decision — case number [CASE NUMBER]
I made a complaint on [DATE OF COMPLAINT] about [NAME OF HEALTH SERVICE OR PRACTITIONER] concerning [ONE-LINE SUMMARY OF THE COMPLAINT].
Your letter dated [DATE OF DECISION LETTER], which I received on [DATE RECEIVED], told me that the Commission decided to [OUTCOME, FOR EXAMPLE: DISCONTINUE THE COMPLAINT / REFER IT FOR LOCAL RESOLUTION].
I request a review of that decision. This request is made in writing within 28 days of receiving the decision letter.
1. What I believe was missed
[POINT 1: WHAT THE DECISION SAYS, AND THE FACT OR RECORD IT DID NOT TAKE INTO ACCOUNT]
[POINT 2]
2. New information
[NEW DOCUMENT OR FACT, DATE, WHY IT MATTERS]
[NEW DOCUMENT OR FACT]
3. What I am asking for
I ask the Commission to review the assessment and to consider [WHAT YOU WANT: FOR EXAMPLE, INVESTIGATION / REFERRAL TO THE RELEVANT COUNCIL / ASSISTED RESOLUTION].
Please confirm receipt of this request and send me the outcome of the review in writing to [EMAIL OR POSTAL ADDRESS].
Attached:
Copy of the decision letter dated [DATE]
[DOCUMENT]
[DOCUMENT]
Yours sincerely,
____________________
[YOUR FULL NAME]
For me
[ ] Date the decision letter arrived: [DATE]
[ ] Last day for the review request (28 days): [DATE]
[ ] Case number quoted in the subject line
[ ] Copies attached, originals kept
[ ] Proof of sending kept