Fact Sheet - Compliant Form Page 2

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DECEMBER 2004
County of Northumberland
Complaint Form (HIPAA)
Regarding the Uses and Disclosures of Health Information
Your Name: ____________________________________ Date: ____________________
Address: _________________________________________ Telephone #:____________
Are you filing this complaint for someone else? ____ Yes ____ No
If yes, whose health information do you believe was violated?
This person’s relationship to you?
Who (or which agency or department) do you believe has violated your (or someone else’s)
privacy rights, or the privacy rules: ___________________________________
When do you believe that the violation occurred? _____________________________
Please explain the nature of you complaint. Please be as specific as possible. (Attach additional
pages if necessary.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I understand that this complaint must be filed within 180-days of when I knew of the actions or
inaction that is the basis of this complaint. I understand that this complaint may be submitted to
the HIPAA Privacy Officer, County of Northumberland, Administration Center, 339 South Fifth
Street, Sunbury, PA 17801. I understand that if the agency or department in which I filed this
complaint against does not reach resolution of this complaint, this complaint will be forwarded to
the Northumberland County Privacy Board for review.
__________________________________________
__________________
Date
Signature

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