FORM AUTO-RESPONSE
TESTING 1-2-3

TESTING 1-2-3
Question, Concern, or Complaint

This form is a test. It does NOT send to the Arizona Ombudsman’s office. Rather, it sends to a very talented web developer. It also SHOULD send a confirmation back to the sender using the sender’s email address from the complaint form. Give it a test.

    Name:

    Email:

    Phone:

    Address:

    City/St/Zip:

    Agency name(s) that your issue is about:

    Question, Concern or Complaint:

    What resolution are you seeking from our agency?

    What steps have you taken to resolve the problem with the agency?

    *Note: Arizona law requires an individual (you) to “exhaust all reasonable alternatives to resolve a complaint within an agency” before our office will review/investigate. Therefore, select and describe the actions below that you have already taken. Please include the names or titles of individuals you have already contacted/worked with, and/or other offices where you tried to resolve your issue.

    Wrote a complaint and sent it to the agency's email, fax, mail.

    Called the agency at telephone #.

    Spoke to agency member or management staff.

    Spoke to the agency's internal ombudsman office on (date).

    Appealed on (date).

    Please explain further resolution attempts or details if you wish:

    Please note the agency case number, license number, or another identifier with this agency if the agency has informed you of one. However, do not send us tax identification or social security numbers.

    Examples: VIN, ATLAS, EIN, Driver License #, DCE Person ID, AHCCCS number, court case #, etc. For DCS cases, if you know, please include the mother and children's names and birth dates.

    Confidentiality with the agency

    In most situation you are already known to the agency, and/or we must identify you as the complaintant to investigate the dispute with the agency. However, sometimes this is not the case. IF you need this complaint to be anonymous to the agency, then you must inform us of that request upfront. If you do require confidentiality, we may not be able to help resolve your complaint, but we may discuss it with you.

    Information Release Forms May Be Required for Certain State Agencies

    If your complaint concerns one of the agencies or programs listed below, you may need to formally give our office permission to inquire about your issue by signing a Release Form. A signed Release Form will authorize the agency to share details with our office. Our office will determine if a Release Form is required and send it to you if necessary.

    • AHCCCS (Arizona Health Care Cost Containment System)

    • ADOR (Arizona Department of Revenue)

    • DCSS (Division of Child Support Services within the Arizona Department of Economic Security)

    • Nutrition Assistance (formerly SNAP Benefits within the Arizona Department of Economic Security)

    • DDD (Division of Developmental Disabilities within the Arizona Department of Economic Security)

    • VR (Vocational Rehabilitation within the Arizona Department of Economic Security)