Complaint/Concern Form

Please Indicate one of the following:		Complaint 		Concern 

I.	 DEMOGRAPHIC INFORMATION

Name:      
Home Address:       						Email:      
City:                                                                         State:                	Zip:                  Tel #:      

II:	What is your relationship to BHM Healthcare Solutions?      

III.	 Please provide a brief description of the nature of your concern/complaint:      

Thank you for providing us with the above information. Your complaint/concern will be investigated. You will receive a written 
complaint resolution letter within thirty (30) calendar days of receipt of the complaint.

*1033 Corporate Square Drive, Suite 102, St. Louis, MO 63132 * Phone: 314-985-5626, Toll Free 888-831-1171, Fax 888-818-2425*