Provider Complaint Form
HCAF exists to provide representation, communication, and advocacy for Florida home care providers, and to give them the education and resources they need to deliver high-quality, cost-effective services to patients and clients at home. We welcome feedback from providers about any issues interfering with or hindering the effective delivery of care and the normal operation of business.

Please complete the form below if you are experiencing any issues and would like HCAF to provide guidance and/or intervene on your behalf. Your submission is confidential. Indicate below if you would like a member of the HCAF staff to contact you after you submit this form.

If you have questions or cannot submit this form, please call (850) 222-8967 or email info@homecarefla.org.

Thank you for supporting HCAF!

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Name of Individual Completing Form *
Home Health Agency Name *
Is your agency an active HCAF member? *
Email Address *
Phone Number *
Where is your agency located? *
What is the general topic of this issue? *
Required
If this concerns a specific entity, please specify. *
If this does not concern a specific entity, please enter "N/A".
What is the approximate date when the issue(s) arose? *
MM
/
DD
/
YYYY
Describe the issue in detail. *
Have you already submitted a complaint to AHCA?
If yes, please provide the Complaint Number associated with your complaint at the end of this form.
Clear selection
In what way would you like HCAF to intervene on your behalf?
Would you like a member of the HCAF staff to contact you about this issue?
Clear selection
If you have any comments or additional information about this issue, please let us know.
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