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