Occupational Therapy Patient Complaint Escalation Form

When patients experience concerns in an occupational therapy practice—whether related to treatment effectiveness, insurance authorization delays, or communication breakdowns—having a clear escalation pathway is essential for maintaining trust and ensuring clinical quality.

This Occupational Therapy Patient Complaint Escalation Form gives your practice a structured process for documenting and addressing serious patient concerns that require clinical director review. The form captures detailed information about treatment concerns, insurance barriers, and communication issues, helping your team route escalations appropriately and respond with accountability.

Built for healthcare providers who care about outcomes

Occupational therapy practices face unique challenges: complex insurance authorization requirements, individualized treatment plans that may need adjustment, and patients with varied communication needs. This template helps you:

• Document treatment effectiveness concerns with specifics about functional goals, progress and patient expectations
• Track insurance authorization issues that may be blocking care or creating financial stress for patients
• Route escalations to the right clinical or administrative leader based on the nature of the concern
• Maintain a clear record of patient grievances for quality improvement and compliance purposes
• Demonstrate responsiveness by acknowledging concerns formally and committing to follow-up timelines

The form uses conditional logic to gather relevant details based on the type of concern raised, ensuring you collect the right information without overwhelming patients with unnecessary questions.

Streamline follow-up with Stepper

After a patient submits an escalation, your team needs to act quickly. With Stepper, you can automate the entire response workflow: route high-priority concerns to your clinical director immediately, notify the treating therapist, schedule follow-up calls, log the escalation in your practice management system, and send acknowledgment emails with expected resolution timelines. This keeps your team coordinated and ensures no patient concern falls through the cracks.

HIPAA considerations

This template is designed for occupational therapy practices but does not include features for HIPAA-compliant PHI handling. If you need to collect protected health information, consider using this form for initial triage only, then follow up through your secure EHR or patient portal for detailed clinical information.

Trusted by healthcare practices that prioritize patient experience and clinical quality, this form template helps you turn complaints into opportunities for improvement while maintaining the professional standards your patients deserve.