By signing this form, I , attest to being fully informed of my rights, as a client of 3Care4U, to file a complaint with the Department of Human Services for any reasons that I may wish to file the complaint. I also attest that I was given written information about the agency's procedure on how to file a complaint including the internal complaint process with the agency's Quality Assessment and Assurance Committee, the phone number, and address of the Division of Quality Assurance where I can file a complaint with DHS.

My signature on this form indicated that the information given to me about the agency's complaint procedure and how I can file a complaint with DHS was explained to me in the language in which I understand whether this language is in English or in another language that I speak. The written information received by me is indicated with a checkmark as below: