Hipaa Non-Privacy Complaint Form

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Form Approved: OMB # 0938-0948
Centers for Medicare & Medicaid Services (CMS)
Office of E-Health Standards and Services (OESS)
HIPAA Non-Privacy Complaint Form
IMPORTANT:
This form cannot be used for HIPAA Privacy complaints. Please direct privacy complaints to the Office for
Civil Rights at 1-800-368-1019 or visit their website:
If you have general questions about the HIPAA Regulations visit our website at:
Please provide your contact information:
(All fields required.)
YOUR NAME (First and Last)
ORGANIZATION NAME
STREET ADDRESS
TELEPHONE NUMBER
CITY/TOWN
COUNTY
STATE
ZIP
Who (or what agency/organization, e.g. health care clearinghouse, health plan, or covered health care
provider) are you filing this complaint against?
(All fields required.)
ORGANIZATION NAME
CONTACT NAME
STREET ADDRESS
TELEPHONE NUMBER
CITY/TOWN
COUNTY
STATE
ZIP
When did this alleged violation occur?
(Required field.)
mm/dd/yyyy
Identify the HIPAA Non-Privacy complaint category?
(Required field.) Select one regulatory category listed below
per complaint submission. Complete this form again to file a complaint for another category listed below.
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Transactions and Code Sets
Unique Identifiers
Security Standards
Describe, in detail, the alleged violation.
(Required field.)
You may attach additional pages as needed. Please enclose copies of
any additional documents (e.g. companion guide, security risk assessment) that may help OESS resolve your complaint.
Please Print or Type.
Please sign and date this complaint. (Required field.)
SIGNATURE:
DATE:
Filing a complaint with CMS is voluntary. However, without the information requested on the complaint form, CMS may be
unable to proceed with a complaint. CMS collects this information under authority of 68 FR 60694 (October 23, 2003) issued
pursuant to the HIPAA. CMS will use the information provided to determine if CMS has jurisdiction and, if so, how CMS will
process the complaint. Information submitted on the complaint 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 only when it is
necessary for investigation of possible HIPAA A.S. Non-Privacy violations, for internal systems operations, or for routine uses,
which include disclosure of information outside the Department for purposes associated with HIPAA A.S. Non-Privacy
compliance and as permitted by law. To submit an electronic complaint, go to our web site at:
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