How to Submit by Mail

Accepting complaints starting January 1, 2024.

If you are unable to file a complaint online, or you need the patient complaint forms in a language other than English, you can print the forms available below and mail them to the Hospital Bill Complaint Program.

What to Include

To file by mail, you will need to send:

  1. Signed and completed Patient Complaint Form.
  2. Signed and completed Authorized Representative Form (if applicable).
  3. Signed and completed Release of Information Form.
  4. Supporting documents (Copies only. Do not send originals).

For convenience, the Patient Complaint Form, Authorized Representative Form, and the Release of Information Form, are combined into a single document below.

Patient Complaint Form

The Patient Complaint Form identifies the information needed to investigate your complaint. Failure to sign the form or provide all the required information may delay or prevent the Hospital Bill Complaint Program’s investigation.

Authorized Representative Form

The Authorized Representative Form lets you give another person permission to help you with your complaint. Your authorized representative may communicate with the Hospital Bill Complaint Program on your behalf, and you can cancel or change your authorized representative at any time.

This form only needs to be signed and completed if you are using an authorized representative. If you will not be using an authorized representative for your complaint, you can leave this form blank, or remove it entirely from the documents mailed to the Hospital Bill Complaint Program.

Download the Authorized Representative Form (English)
Descarga el Formulario de Representante Autorizado (Español)
Other languages available below.

Release of Information

Your health information is protected and cannot be shared without your permission. The Release of Information Form gives the hospital permission to share your medical records and information with the Hospital Bill Complaint Program. Without this authorization to release your health information, the Hospital Bill Complaint Program cannot process or investigate your complaint.

Supporting Documents

Supporting documents are the documents necessary to support your complaint against the hospital. In other words, supporting documents are any documents that provide additional information about your issue and provide documented proof of any potential wrongdoing. Some examples include:

  • Your hospital bill.
  • Paystubs or tax returns.
  • Hospital notices or letters about your bill.
  • Letters denying discount payment or charity care.
  • Notices or letters from collections.

You may also provide a written description about the problem you are having with your hospital bill. For example, you can explain that you did not receive notices that are required by law or that you were wrongfully denied financial assistance.

Please only send copies of your documents. Do not send originals. Documents will not be returned.

Mail your signed and completed complaint forms with copies of any supporting documents to:

Department of Health Care Access and Information
Hospital Bill Complaint Program
2020 West El Camino Avenue, Suite 1101
Sacramento, CA 95833

Printable Patient Complaint Forms
(Many Languages Available)

The Patient Complaint Form, Authorized Representative Form, and the Release of Information Form, are combined into a single document below.

EnglishPatient Complaint Form
SpanishFormulario de Reclamos sobre Facturas de Hospitales
Arabicنموذج شكوى بشأن فاتورة المستشف
Farsiفرم شکایت درباره صورت‌حساب بیمارستان
Filipino/TagalogPorma Para Sa Reklamo Tungkol Sa Bayarin Sa Ospital
Hindiअस्पताल बिल शिकायत फॉर्म
HmongDaim Ntawv Foos Teev Kev Tsis Txaus Txog Kev Sau Nqi Mus Pwv Hauv Tsev Kho Mob
Korean병원 진료비 불만제기 양식
MienSou-Daan Liouh Fiev Guaix Waac Sou Gorngv Siou Nyaanh Yiem Zorc Baengc Dorngh
Punjabiਹਸਪਤਾਲ ਬਿੱਲ ਸ਼ਿਕਾਇਤ ਫਾਰਮ
Tagalog/FilipinoPorma Para sa Reklamo Tungkol sa Bayarin sa Ospital

The patient complaint forms can be translated into additional languages upon request. Submit a translation request below.

Get Help

For free assistance with your complaint, you may contact the Health Consumer Alliance by visiting, or by calling (888) 804-3536.