North Florida Pediatrics, Pa Hipaa Privacy Complaint Form printable pdf download

NORTH FLORIDA PEDIATRICS, PA

HIPAA Privacy Complaint Form

Use this form to complain about violation of your privacy rights, including your rights under the Privacy Regulation

that the Department of Health and Human Services (“DHHS”) promulgated to implement the Health Insurance

Portability and Accountability Act of 1996 (“HIPAA”). You may submit your complaint to the Operations Director

at 1859 SW Newland

If your complaint involves a violation of HIPAA, you may also complain directly to DHHS. To file your complaint

directly to DHHS, you must file your complaint with the Dept. of Health and Human Services, Office of Civil

Rights, at Sam Nunn Atlanta Federal Center, Suite 16T70, 61 Forsyth St. SW Atlanta, GA 30303-8909. You may

obtain a DHHS complaint form at

Individual Filing Complaint

Last name: _______________________ First name: _____________________ Middle initial: __

Street address: _______________________ City: ______________ State: ____ Zip code: _____

Daytime phone number: __________________ Evening Phone Number: ___________________

Email address: __________________________ Best time to reach you: ____________________

Consent to Disclose Your Name

Please select one of the following:

 I consent to my name being disclosed to investigate this complaint.

 I do not consent to my name being disclosed. Please note that not using your name may limit or delay

our ability to investigate this complaint.

Information about Your Complaint

Name of Organization/Office/Department that your complaint is against: ___________________

Name of person(s) that your complaint is against: _____________________________________

Date(s) that action(s) giving rise to your complaint occurred: ____________________________

Details of the Complaint

I have reason to believe that one or more of the following occurred:



The organization/person has inappropriately disclosed my health information or other personal

information.



The organization/person has inappropriately used my health information or other personal information.



The organization/person has inappropriately disposed of my health information or other personal

information.



The organization/person has inappropriately denied me or my personal representative access to my health

information or other personal information.



The organization/person has inappropriately denied my request to amend/correct my health information or

other personal information.

HIPAA Privacy Complaint Form

Sept 20, 2013

North Florida Pediatrics, Pa Hipaa Privacy Complaint Form