Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form

Status: Original and derived artifacts are available for this document.

Download: pdf

An official website of the United States government Here’s how you know

Emergency Medical
Treatment and Labor Act
(EMTALA)
Emergency department rights
Video about your rights
How to file an EMTALA
complaint

Your EMTALA rights:

How to file a complaint about a
hospital emergency department
If you believe your EMTALA rights have been violated by a hospital
emergency department, you can file an EMTALA complaint.


Filing an EMTALA complaint isn’t a legal action. You’re helping to make sure
hospitals stabilize emergency medical conditions and follow the law.


Prepare before you file a complaint
Know your rights under the Emergency Medical Treatment and Labor
Act (EMTALA)
You’ll need to give details about what happened. For example, the
hospital name, patient name (if you choose to), and what happened,
including the date. You can file a complaint anonymously
File your complaint as soon as possible. This will make it easier to keep
track of the facts, and it may help if you choose to take legal action on
your own. 


To file a complaint
There are 2 ways to file a complaint about a possible EMTALA violation:
Contact the State Survey Agency in the state where the hospital is
located.
Use the online form linked here. The federal government will review your
complaint and might share it with the state.

File an EMTALA complaint
If you already filed a complaint and have more information or want to
contact us, please file another complaint.

What to expect
If you use the online form and provide your email, you'll get an email
confirming that the federal government got your complaint.


The federal government and the states work together to review and
investigate EMTALA complaints. Often a State Survey Agency conducts the
investigation, if there is one. After an investigation, the federal government
reviews the case and determines if a hospital violated EMTALA. The process
can take weeks or months, depending on the nature of the complaint.

 

If you provide your contact information, an investigator might contact you
with questions. Even if you don’t speak to an investigator, you’ll get a
summary of the investigation.

 

If your complaint is about a situation EMTALA doesn’t cover, it will be sent to
the right office, or closed.


Privacy Act Statement - Effective February 22, 2024
Protecting your privacy is very important to us. The Centers for
Medicare and Medicaid Services (CMS) intend to collect information from
anyone who wishes to file a complaint under the Emergency Medical
Treatment and Labor Act (EMTALA). 42 U.S.C. §1395dd and 42 CFR
§489.24 allow us to collect this information about a potential EMTALA
violation. 

 

It’s voluntary to provide your information on the EMTALA complaint form;
however, if you don’t provide information about a potential EMTALA
violation, it might limit our ability to investigate and help resolve the
situation. 

 

As permitted by the Privacy Act of 1974 and all applicable routine uses,
CMS may use or share your information to determine if an EMTALA
violation has occurred. 

 

Details about the use of your information are in the System of Records
Notice “Automated Survey Processing Environment (ASPEN) Complaints/
Incidents Tracking System (ACTS),” System No. 09-70-0565.

Paperwork Reduction Act Statement
OMB Control Number: 0938-1185

This form expires on March 31, 2026 


According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this
information collection is 0938-1185. This information collection is to allow
individuals to submit complaints of their experiences within Hospital
Emergency Departments.

 

The time required to complete this information collection is
estimated to average less than 5 minutes per response, including the
time to review instructions, search existing data resources, gather
the data needed, to review and complete the information
collection. This information collection is voluntary, and if you choose,
confidential.

 

If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to:

CMS

7500 Security Boulevard

Attn: PRA Reports Clearance Officer

Mail Stop C4-26-05

Baltimore, Maryland 21244-1850

OMB Control Number: 0938-1185

An official website of the United States government Here’s how you know

File an EMTALA complaint
Before filing a complaint, know your rights under the Emergency Medical Treatment and Labor
Act (EMTALA). Anyone can file an EMTALA complaint.

EMTALA complaint about a hospital
emergency department

1

The questions in this form are required unless marked “optional”.

Would you like to provide contact information or file anonymously?
I'll provide my contact information
If we have questions about your complaint, we might contact you. Below, you can let us know if you have
any concerns about sharing your information with the state where the hospital is located.

I’ll remain anonymous
We investigate anonymous complaints. Please note that sometimes while gathering information,
investigators reach out to patients and other people they identify in hospital records.

Your contact information


Provide your own contact information, even if you’re filing this complaint for someone
else. Sometimes we have questions, and it’s very helpful if we can contact you.

First name
Mary

PRA Note: These are revealed
if user selects “I’ll provide my
contact information”.
Otherwise they are hidden.

Last name

Jane Doe
Phone (optional)
(952)607-1456
Email (optional)

[email protected]

What is your relationship to the patient?
I'm the patient
I'm filing a complaint for someone else
I work at this hospital

I prefer not to say

Let us know where the problem happened

2

Where is the hospital emergency department?
Select a U.S. state or territory

PRA Note: Based on
selection, the Hospital Name

Minnesota

and Address auto-populates
based on CMS Data.

Hospital name
Hennepin County Medical Center

Here’s the address we have for this hospital emergency department:
Hennepin County Medical Center Emergency Room

900 S 8th Street

Minneapolis, Minnesota 55415

If this hospital information isn’t correct, let us know under “Tell us what happened.”

Tell us what happened

3

When did the problem happen?
If you’re not sure, give your best estimate.
Date

Tell us what happened.
Describe the situation in detail. Be sure to include:

The people who were involved (Examples: witnesses, hospital staff
What actions you too
If the hospital tried to address the situatio
Any concerns about sharing your information with the state

3000 characters allowed

Have you reported this problem before? (optional)
If so, who did you report this problem to

7

w

1 5 characters allo ed

Review your complaint

?