Fact Sheet - Compliant Form printable pdf download

COUNTY OF NORTHUMBERLAND

FACT SHEET – COMPLAINT FORM

How to File a Health Information Complaint with the County of Northumberland

The County of Northumberland takes seriously its responsibility to protect the privacy

and security of individual health information, and to ensure that such information is used

appropriately in and accordance with all applicable laws and regulations. Individuals

have a right to file a formal complaint if they believe that their (or someone else’s)

privacy rights have been violated. The County of Northumberland encourages

individual’s to exercise their right to file a complaint if they believe that their (or

someone else’s) privacy rights have been violated. There will be no retaliation of any

kind for filing a complaint.

Complaints to the County of Northumberland must be filed in writing, and must name the

individual (or agency or department) that is the subject to the complaint. Complaints

should be filed within 180 days of when you knew that the alleged violation occurred.

The complaint will be forwarded to the agency or department in which the believed

violation occurred for resolution, if the complaint cannot be resolved on this level, the

agency or department’s Privacy Officer will bring the complaint to the Northumberland

County Privacy Board for review.

Anyone can file a written complaint with the County of Northumberland. You can submit

your compliant in any written format. We recommend that you use the County of

Northumberland Complaint Form, which can be found on the County web site

, or at any County Office, or, you may submit a written

complaint in your own format. Be sure to include the following information in your

written complaint:

• Your name, full address, telephone number(s).

• If you are filing the complaint on someone else’s behalf, also provide the name of

the person on whose behalf you are filing.

• Name of the person, agency or department you believe violated your (or someone

else’s) health information privacy rights or committed another violation of the

Privacy Rule.

• Briefly describe what happened and why, how and when you believe the

violation occurred.

• Add any other relevant information.

The Privacy Rule, developed under the Health Information Portability and Accountability

Act of 1996 (HIPAA), prohibits the retaliation, in any form, against and individual who

files a privacy complaint. If you feel that you have been threatened, harmed, or retaliated

against in any way, contact the HIPAA Privacy Officer, County of Northumberland, at

(570) 495-2212, or in writing to County of Northumberland, HIPAA Privacy Officer,

Administration Center, 339 South Fifth Street, Sunbury, PA 17801.

Fact Sheet - Compliant Form