Health Information Privacy Complaint (Page 3 of 8) in pdf

COMPLAINANT CONSENT FORM

The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR)

has the authority to collect and receive material and information about you, including

personnel and medical records, which are relevant to its investigation of your complaint.

To investigate your complaint, OCR may need to reveal your identity or identifying

information about you to persons at the entity or agency under investigation or to other

persons, agencies, or entities.

The Privacy Act of 1974 protects certain federal records that contain personally identifiable

information about you and, with your consent, allows OCR to use your name or other

personal information, if necessary, to investigate your complaint.

Consent is voluntary, and it is not always needed in order to investigate your complaint;

however, failure to give consent is likely to impede the investigation of your complaint

and may result in the closure of your case.

Additionally, OCR may disclose information, including medical records and other personal

information, which it has gathered during the course of its investigation in order to comply

with a request under the Freedom of Information Act (FOIA) and may refer your complaint

to another appropriate agency.

Under FOIA, OCR may be required to release information regarding the investigation of

your complaint; however, we will make every effort, as permitted by law, to protect

information that identifies individuals or that, if released, could constitute a clearly

unwarranted invasion of personal privacy.

Please read and review the documents entitled,

Notice to Complainants and Other

Individuals Asked to Supply Information to the Office for Civil Rights

and

Protecting

Personal Information in Complaint Investigations

for further information regarding how

OCR may obtain, use, and disclose your information while investigating your complaint.

In order to expedite the investigation of your complaint if it is accepted by OCR,

please read, sign, and return one copy of this consent form to OCR with your

complaint. Please make one copy for your records.

As a complainant, I understand that in the course of the investigation of my

•

complaint it may become necessary for OCR to reveal my identity or identifying

information about me to persons at the entity or agency under investigation or to

other persons, agencies, or entities.

Complaint Consent Form

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Health Information Privacy Complaint Page 3