For when a Medicare-participating hospital with a dedicated emergency department refused screening, refused stabilizing treatment, inappropriately transferred or discharged, or denied emergency care over insurance/payment concerns.
This is a regulatory complaint to CMS (and the state survey agency that investigates on CMS's behalf). For the civil action under 42 U.S.C. § 1395dd(d)(2)(A), the patient should retain counsel; the 2-year statute of limitations is unforgiving.
If the violation is happening now or is imminent (e.g., a hospital is currently refusing care), call 9-1-1 for emergency assistance and contact the state CMS Regional Office immediately by phone.
[PATIENT FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
Phone: [PATIENT PHONE]
Email: [PATIENT EMAIL]
[DATE]
[CMS Regional Office, find at cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act/contacts]
[REGIONAL OFFICE MAILING ADDRESS]
with copy to:
[State survey agency for hospital licensure, typically the state health department]
[STATE SURVEY AGENCY MAILING ADDRESS]
VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED
USPS Tracking: [CERTIFIED MAIL TRACKING NUMBER]
RE: EMTALA complaint, 42 U.S.C. § 1395dd; 42 CFR § 489.24
Hospital: [HOSPITAL LEGAL NAME]
Hospital address: [HOSPITAL ADDRESS]
CMS Certification Number (if known): [CCN]
Date(s) of violation: [DATE(S)]
Complainant: [PATIENT or relative/representative name]
Patient: [PATIENT FULL NAME, if different from complainant]
Date of birth: [DOB]
Sex: [SEX, as recorded by the hospital, relevant if violation involved active labor]
To the CMS Regional Office:
I am filing a formal complaint under the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, regarding the conduct of [HOSPITAL LEGAL NAME] on [DATE(S) OF VIOLATION].
I. Summary of facts
[Describe in chronological order, in plain language, what happened. Stick to facts you observed directly or that are documented in records you have. Examples below; the LLM should render only the applicable subset and add any additional facts the patient describes.]
[BLOCK A, Failure to provide a medical screening examination]
On [DATE] at approximately [TIME], I arrived at [HOSPITAL]'s emergency department complaining of [SYMPTOMS]. Upon arrival, [registration staff / a nurse / triage personnel] asked about my insurance status. After I [told them I was uninsured / said I could not pay / mentioned a prior unpaid bill], I was told [exact words or paraphrase] and I [was sent away without examination / was made to wait without screening for X hours while other patients were seen / other]. I did not receive a medical screening examination by qualified personnel.
[BLOCK B, Failure to provide stabilizing treatment]
On [DATE], after a medical screening examination at [HOSPITAL] identified [emergency medical condition, example: active chest pain, acute appendicitis, hemorrhage, active labor], I was [discharged in an unstable condition / refused further treatment / told to seek care elsewhere] before stabilization. The connection to insurance or payment was [explicit, staff stated they would not treat without payment / implicit, the conversation about payment immediately preceded the decision to discharge].
[BLOCK C, Inappropriate transfer]
On [DATE], I was transferred from [HOSPITAL] to [RECEIVING FACILITY] while in an unstable condition. The transfer occurred [without my informed consent / without physician certification that benefits outweigh risks / without the receiving facility's confirmed acceptance / without appropriate transport equipment and personnel]. The connection to payment was [as above].
[BLOCK D, Refusal of emergency care over a prior unpaid bill]
On [DATE], I sought emergency care at [HOSPITAL] for [SYMPTOMS]. Hospital staff [refused to admit me / told me I could not return until I paid a prior bill / threatened to refuse care for future emergencies]. The hospital is a Medicare-participating facility with a dedicated emergency department; the refusal is a direct violation of EMTALA.
[BLOCK E, Active labor]
On [DATE], I (or [PATIENT]) presented at [HOSPITAL]'s emergency department in active labor. The hospital [refused to admit me / discharged me before delivery / inappropriately transferred me while in active labor]. The connection to insurance or payment was [as above].
[END BLOCKS]
II. Personnel involved (if known)
- [Name and role, if known: registration clerk, triage nurse, attending physician, charge nurse]
- [Name and role of any supervisor I asked to speak with]
If names are not known, please request the hospital's records for the relevant date and time as part of your investigation.
III. Documentation enclosed
- Exhibit A: My medical records from [HOSPITAL] for the date(s) at issue, if obtained
- Exhibit B: Records from [RECEIVING FACILITY] showing my condition on arrival (for transfer cases)
- Exhibit C: Any written documentation from the hospital (discharge papers, transfer forms, refusal-to-treat forms, bills referencing the encounter)
- Exhibit D: Witness statements, if any
- Exhibit E: Copy of any threatening communication from the hospital about future care
If I do not have direct access to records, I will sign a release authorizing CMS and the state survey agency to obtain them.
IV. Specific requests
I respectfully request that the Centers for Medicare and Medicaid Services and the state survey agency:
1. Open an investigation under 42 U.S.C. § 1395dd and 42 CFR § 489.24 into the conduct described above.
2. Take appropriate enforcement action, including civil monetary penalties under 42 U.S.C. § 1395dd(d)(1) and termination of the hospital's Medicare provider agreement if warranted.
3. Provide me written notification of the outcome of the investigation.
V. Notice of preservation of rights
I am preserving all rights under 42 U.S.C. § 1395dd(d)(2)(A) to bring a civil action against [HOSPITAL] for personal harm resulting from this conduct, and any rights under state malpractice and consumer-protection law.
Thank you for your prompt attention to this matter. Patients depend on EMTALA to ensure emergency care is provided without regard to ability to pay, and credible enforcement is essential to that protection.
Sincerely,
[PATIENT FULL NAME or COMPLAINANT FULL NAME]
Date of incident: [DATE(S)]
Patient: [PATIENT FULL NAME]
DOB: [DOB]
cc:
[STATE SURVEY AGENCY (typically the state health department's Bureau of Health Facility Standards or analogous office)]
[STATE ATTORNEY GENERAL Consumer Protection Division, where applicable]
[Patient's counsel, if engaged]
Enclosures: as listed in Section III
- The LLM must render only the scenario block(s) that match the patient's facts; do not pad with unused blocks.
- Witness statements (Exhibit D) are valuable, if a friend or family member witnessed the events, get a brief signed statement from them describing what they observed. Date the statement.
- If records are not yet obtained, that is fine; the complaint can still be filed and CMS will request them as part of the investigation. The patient can also separately file a HIPAA right-of-access request, see
templates/complaint_hipaa_access.md.
- Federal CMS: find the right Regional Office (10 nationwide) at cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act/contacts.
- State survey agency: in most states, the state health department's hospital-licensure office. Examples: Tennessee Department of Health Office of Healthcare Facilities, California Department of Public Health Licensing and Certification, Florida Agency for Health Care Administration. Find via state government website search.
- Parallel filings: state attorney general (for any deceptive-practice angle), state hospital licensure office, and the hospital's accreditation body (Joint Commission at jointcommission.org/resources/patient-safety-topics/report-a-patient-safety-event-or-concern/).
42 U.S.C. § 1395dd(d)(2)(C) sets a 2-year statute of limitations for the civil action from the date of the violation. The CMS regulatory complaint has no equivalent SOL but should be filed as soon as practicable for evidentiary reasons.
- The hospital provided emergency care but the bill is excessive: use
letter_initial_dispute.mdorletter_no_surprises_violation.md. - The insurance denied an emergency claim: use
letter_insurance_appeal_erisa.md. - The patient was denied non-emergency care over an unpaid bill: EMTALA is emergency-only; use state UDAP or anti-discrimination statutes.
The LLM logs this with action_type = "emtala_complaint_filed". Set response_due_by to 90 days from filing as a check-in milestone. CMS investigations typically take 6-12 months.
For the civil action: state bar lawyer referral services often have specialized panels for medical malpractice and patient-injury cases. Many take EMTALA cases on contingency. Patients should not delay, the 2-year clock runs from the date of the violation.