North Florida Pediatrics, Pa Hipaa Privacy Complaint Form (Page 2 of 2) in pdf

North Florida Pediatrics, Pa Hipaa Privacy Complaint Form Page 2



The organization/person has inappropriately denied my request to restrict uses and disclosures of my

health information or other personal information.



The organization/person has inappropriately violated the alternate communication method that I specified.



The organization’s privacy policies and procedures violate the law.



Other (specify).

Please provide a detailed description of your complaint, including what, when, who, where, and why. You may

attach additional pages or documentary evidence.

Do you have witnesses?



Yes.



No.

If Yes, please provide the names, addresses, and telephone numbers of your witness(es) below:

Witness name: _____________________________________ Phone number: _______________

Address: ______________________________________________________________________

Witness name: _____________________________________ Phone number: _______________

Address: ______________________________________________________________________

Witness name: _____________________________________ Phone number: _______________

Address: ______________________________________________________________________

Resolution of Your Complaint

Please describe how you believe that your complaint could be resolved:

North Florida Pediatrics may decide that your complaint does not violate the HIPAA Privacy Rule or any other

applicable law or regulation, but another organization may be able to help you. Please choose one of the following:



I agree to have this complaint disclosed to another organization.



I do not agree to have this complaint disclosed to another organization.

Your Signature

I certify that the information on this form is true and correct to the best of my information, knowledge, and belief.

Signature ______________________________________ Date:___________________________

HIPAA Privacy Complaint Form

Sept 20, 2013

North Florida Pediatrics, Pa Hipaa Privacy Complaint Form Page 2