Health Information Privacy Complaint (Page 4 of 8) in pdf

Health Information Privacy Complaint Page 4

I am also aware of the obligations of OCR to honor requests under the Freedom of

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Information Act (FOIA). I understand that it may be necessary for OCR to disclose

information, including personally identifying information, which it has gathered as

part of its investigation of my complaint.

In addition, I understand that as a complainant I am covered by the Department of

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Health and Human Services’ (HHS) regulations which protect any individual from

being intimidated, threatened, coerced, retaliated against, or discriminated against

because he/she has made a complaint, testified, assisted, or participated in any

manner in any mediation, investigation, hearing, proceeding, or other part of HHS’

investigation, conciliation, or enforcement process.

After reading the above information, please check ONLY ONE of the following boxes:

CONSENT: I have read, understand, and agree to the above and give permission

to OCR to reveal my identity or identifying information about me in my case file to

persons at the entity or agency under investigation or to other relevant persons, agencies,

or entities during any part of HHS’ investigation, conciliation, or enforcement process.

CONSENT DENIED: I have read and I understand the above and do not give

permission to OCR to reveal my identity or identifying information about me. I

understand that this denial of consent is likely to impede the investigation of my

complaint and may result in closure of the investigation.

Date:

Signature:

*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.

Name (Please print):

Address:

Telephone Number:

Complaint Consent Form

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Health Information Privacy Complaint Page 4