Health Information Privacy Complaint (Page 2 of 8) in pdf

The remaining information on this form is optional. Failure to answer these voluntary

questions will not affect OCR's decision to process your complaint.

Do you need special accommodations for OCR to communicate with you about this complaint? (Check all that apply)

Braille

Large Print

Cassette tape

Computer diskette

Electronic mail

TDD

Sign language interpreter (specify language):

Foreign language interpreter (specify language):

Other:

If we cannot reach you directly, is there someone we can contact to help us reach you?

FIRST NAME

LAST NAME

HOME PHONE (Please include area code)

WORK PHONE (Please include area code)

STREET ADDRESS

CITY

STATE

ZIP

E-MAIL ADDRESS (If available)

Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed)

PERSON / AGENCY / ORGANIZATION / COURT NAME(S)

DATE(S) FILED

CASE NUMBER(S) (If known)

To help us better serve the public, please provide the following information for the person you believe had their health

information privacy rights violated (you or the person on whose behalf you are filing).

ETHNICITY (select one)

RACE (select one or more)

Hispanic or Latino

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Black or African American

White

Other (specify):

PRIMARY LANGUAGE SPOKEN (if other then English)

How did you learn about the Office for Civil Rights?

HHS Website/Internet Search

Family/Friend/Associate

Religious/Community Org

Lawyer/Legal Org

Phone Directory

Employer

Fed/State/Local Gov

Healthcare Provider/Health Plan

Conference/OCR Brochure

Other (specify):

To submit a complaint, please type or print, sign, and return completed complaint form package (including consent form) to the

OCR Headquarters address below.

U.S. Department of Health and Human Services

Office for Civil Rights

Centralized Case Management Operations

200 Independence Ave., S.W.

Suite 515F, HHH Building

Washington, D.C. 20201

Customer Response Center: (800) 368-1019

Fax: (202) 619-3818

TDD: (800) 537-7697

Email: ocrmail@hhs.gov

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for reviewing

instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor,

and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate

or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information

Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201. Please do not mail this complaint form to this address.

HHS-700 (7/09) (BACK)