Hipaa Complaint Report Page 2
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2For Internal Use Only:
Privacy Officer’s acknowledgement of receipt: _________________________________
Complaint was delivered by:
Personal delivery
Regular mail
(Circle One)
E-mail
Voice-mail
Date received: ____/____/____
Time received ____: ____ a.m./p.m.
Communicated to Privacy Liaison at _____________________________
Privacy Liaison’s acknowledgement of receipt: ___________________________
Date received: ____/____/____
Time received ____: ____ a.m./p.m.
Process of investigation: ___________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Formal action taken/resolution: _____________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________________________
________________________
Privacy Liaison’s Signature
Date
Comments by the Privacy Officer: ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________
____________________________
Privacy Officer’s Signature
Date
Page 2 of 2
Last Revision 5/23/2013
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Parent category: Medical