Division of HIV and STD Programs
600 S. Commonwealth Ave., 10th Floor, Los Angeles, CA 90005
Customer Support Form

The Division of HIV and STD Programs’ (DHSP) Customer Support Program aims to assist consumers of HIV and STD services who have experienced difficulty accessing services from DHSP-funded providers throughout Los Angeles County. If you need assistance or have a concern regarding your HIV or STD services that you have not been able to resolve with the provider directly, please feel free to share with us by completing the form below.

To make it as easy as possible, you may submit the completed form by clicking the submit button at the bottom of the form. You can also email us directly at DHSPsupport@ph.lacounty.gov or contact us by phone at (800) 260-8787. Please feel free to reach out with any questions or if you need further assistance.

What happens after I contact DHSP Customer Support Unit?

DHSP staff will contact you regarding your concerns within 2 business days of receipt of your form or message. For questions about services or resources available in Los Angeles County, we will provide you with the information you are requesting and where to go to receive services. For issues or complaints regarding services you have received, we will then work closely with you and can provide assistance with seeking resolutions such as by filing a grievance with the service provider or by providing referrals or information about available services that meet your needs. You will also be welcome to remain anonymous through the process if you prefer.

Your feedback is important to us. Please complete our customer satisfaction survey by clicking the link below:

Customer Satisfaction Survey

Question Title

* YOUR INFORMATION

Name (First, Middle and Last)

Patient/Client Name if different from customer:

Street Address

City

Zip Code

Phone Number

E-mail

Preferred Language

Question Title

* Confidentiality:

	Yes	No
Can we leave a voice message?	Can we leave a voice message? Yes	Can we leave a voice message? No
Can we share your name with the agency?	Can we share your name with the agency? Yes	Can we share your name with the agency? No

Question Title

* Preferred Pronouns:

He/Him

She/Her

They/Them

Other (please specify)

Question Title

* Which is the best way to keep in touch with you?

Phone call

E-mail

Mail/Letter

No written communication from us (DHSP)

Any/No preferences

Other (please specify)

Question Title

* What type of assistance do you need?

Linkage to HIV/STD services

File a complaint

Community resources

Offer feedback

Other (please specify)

Question Title

* For Linkage or Resource Request: Describe assistance that you need.

Question Title

* For Feedback:

TO FILE A COMPLAINT: Fill in the form below and provide as much details as you can.

Question Title

* SERVICE PROVIDER/ AGENCY INFORMATION

Agency Name

Service Location Street Address

City

Zip Code

Question Title

* Service Category:

Medical Care

Medical Case Management

Dental Care

Mental Health

Nutrition/ Food Support

HIV/ STD Testing

PrEP Services

Benefits Specialty

Legal Services

Residential Facility

Transportation

Other (please specify)

Question Title

* Did you file a complaint with the agency?

Yes

Question Title

* If YES:

When (date)?

With whom?

What was the result?

COMPLAINT DETAILS:

Question Title

* Complaint Type (check all that apply):

Ability to Get Care/ Service (i.e., denial, scheduling)

Billing

Confidentiality and Privacy

Enrollment/ Benefits

Eviction

Facility Environment/ Accommodations

HIV Patient's Rights Violation

Quality of Care (i.e., substandard care)

Medical Provider Issues

Staff Issues

Customer Service

DHSP Staff

Other (please specify)

Question Title

* Please describe your complaint. Attach additional pages or supporting documents as needed.

When did this happen (date of incident)?

Name of person involved?

Name of person witnessed the incident?

Question Title

* What happened?

Question Title

* Attach additional document if any:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* Desired Outcome (what would reasonably resolve this concern for you)?

Question Title

* COMPLETE IF AUTHORIZING A REPRESENTATIVE TO FILE A COMPLAINT ON YOUR BEHALF

Name of Representative

Relationship to Patient/Client

Phone Number

Question Title

* Consent:

	Yes	Not Applicable
I authorized the person or entity named above to serve as my representative for this complaint.	I authorized the person or entity named above to serve as my representative for this complaint. Yes	I authorized the person or entity named above to serve as my representative for this complaint. Not Applicable
I authorized DHSP staff to assist me with filing a grievance with the service provider (agency).	I authorized DHSP staff to assist me with filing a grievance with the service provider (agency). Yes	I authorized DHSP staff to assist me with filing a grievance with the service provider (agency). Not Applicable

Division of HIV and STD Programs 600 S. Commonwealth Ave., 10th Floor, Los Angeles, CA 90005Customer Support Form

Question Title

* YOUR INFORMATION

Question Title

* Confidentiality:

Question Title

* Preferred Pronouns:

Question Title

* Which is the best way to keep in touch with you?

Question Title

* What type of assistance do you need?

Question Title

* For Linkage or Resource Request: Describe assistance that you need.

Question Title

* For Feedback:

Question Title

* SERVICE PROVIDER/ AGENCY INFORMATION

Question Title

* Service Category:

Question Title

* Did you file a complaint with the agency?

Question Title

* If YES:

Question Title

* Complaint Type (check all that apply):

Question Title

* Please describe your complaint. Attach additional pages or supporting documents as needed.

Question Title

* What happened?

Question Title

* Attach additional document if any:

Question Title

* Desired Outcome (what would reasonably resolve this concern for you)?

Question Title

* COMPLETE IF AUTHORIZING A REPRESENTATIVE TO FILE A COMPLAINT ON YOUR BEHALF

Question Title

* Consent:

Division of HIV and STD Programs
600 S. Commonwealth Ave., 10th Floor, Los Angeles, CA 90005
Customer Support Form