Health Information Privacy Complaint

ADVERTISEMENT

Form Approved: OMB No. 0990-0269.
See OMB Statement on Reverse.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE FOR CIVIL RIGHTS (OCR)
HEALTH INFORMATION PRIVACY COMPLAINT
YOUR FIRST NAME
YOUR LAST NAME
HOME PHONE (Please include area code)
WORK PHONE (Please include area code)
STREET ADDRESS
CITY
STATE
ZIP
E-MAIL ADDRESS (If available)
Are you filing this complaint for someone else?
Yes
No
If Yes, whose health information privacy rights do you believe were violated?
FIRST NAME
LAST NAME
Who (or what agency or organization, e.g., provider, health plan) do you believe violated your (or someone else’s) health
information privacy rights or committed another violation of the Privacy Rule?
PERSON / AGENCY / ORGANIZATION
STREET ADDRESS
CITY
STATE
ZIP
PHONE (Please include area code)
When do you believe that the violation of health information privacy rights occurred?
LIST DATE(S)
Describe briefly what happened. How and why do you believe your (or someone else’s) health information privacy rights were
violated, or the privacy rule otherwise was violated? Please be as specific as possible. (Attach additional pages as needed)
Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.
SIGNATURE
DATE (mm/dd/yyyy)
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your
complaint. We collect this information under authority of the Privacy Rule issued pursuant to the Health Insurance Port ability and
Accountability Act of 1996. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your
complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974.
Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible health information
privacy violations, for internal systems operations, or for routine uses, which include disclosure of information outside the Department for
purposes associated with health information privacy compliance and as permitted by law. It is illegal for a covered entity to intimidate,
threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the
Privacy Rule. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same
information. To submit an electronic complaint, go to OCR’s Web site at: To
submit a complaint using alternative methods, see reverse page (page 2 of the complaint form).
HHS-700 (7/09)
(FRONT)
EF
PSC Graphics (301) 443-1090

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 8