Hipaa Complaint Report

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HIPAA COMPLAINT REPORT
Your Name: ____________________________________________________
Address: _______________________________________________________________
Telephone Number: __________________________
Fax: ___________________
E-mail address: ______________________________
Date: ___________________
If you are filing a complaint on someone’s behalf, provide the name and address of the
person on whose behalf you are filing.
Name: _________________________________________________________
Address: _______________________________________________________________
Information about Suspected Privacy Violation:
What component* of the University is suspected of privacy violation: _______________
_______________________________________________________________________
*Purdue is a “hybrid entity” under federal HIPAA privacy regulations. Only ”covered components”
named in the Notices of Privacy Practices are subject to these regulations.
Some of the covered
components include, for example, the Student Health Center, Purdue Pharmacy, and the Purdue Health
Plans. Please refer to the Notices of Privacy Practices available from the Privacy Officer or on the Purdue
web page
for a complete listing of the covered components.
Please describe in detail the nature of your privacy complaint, including the date or dates
of the incident(s), and the name or names of any Purdue personnel involved and other
witnesses (attach additional sheets if necessary):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________
________________________
Patient or Legal Representatives’ Signature
Date
_____________________________________________________
Send to:
Relationship (if not patient)
Privacy Officer
601 Stadium Mall Drive
To file a complaint with the Office for Civil Rights, access:
West Lafayette, IN 47907-2052
Or Email: hipaa-privacy@purdue.edu
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Last Revision 5/23/2013

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