Form Hhs-700 - Civil Rights Discrimination Complaint Page 3
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8COMPLAINANT CONSENT FORM
The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has the authority to
collect and receive material and information about you, including personnel and medical records, which
are relevant to its investigation of your complaint.
To investigate your complaint, OCR may need to reveal your identity or identifying information about you
to persons at the entity or agency under investigation or to other persons, agencies, or entities.
The Privacy Act of 1974 protects certain federal records that contain personally identifiable information
about you and, with your consent, allows OCR to use your name or other personal information, if
necessary, to investigate your complaint.
Consent is voluntary, and it is not always needed in order to investigate your complaint; however, failure
to give consent is likely to impede the investigation of your complaint and may result in the closure of
your case.
Additionally, OCR may disclose information, including medical records and other personal information,
which it has gathered during the course of its investigation in order to comply with a request under the
Freedom of Information Act (FOIA) and may refer your complaint to another appropriate agency.
Under FOIA, OCR may be required to release information regarding the investigation of your complaint;
however, we will make every effort, as permitted by law, to protect information that identifies individuals
or that, if released, could constitute a clearly unwarranted invasion of personal privacy.
Please read and review the documents entitled, Notice to Complainants and Other Individuals Asked to
Supply Information to the Office for Civil Rights and Protecting Personal Information in Complaint
Investigations for further information regarding how OCR may obtain, use, and disclose your information
while investigating your complaint.
In order to expedite the investigation of your complaint if it is accepted by OCR, please read, sign,
and return one copy of this consent form to OCR with your complaint. Please make one copy for
your records.
•
As a complainant, I understand that in the course of the investigation of my
complaint it may become necessary for OCR to reveal my identity or identifying
information about me to persons at the entity or agency under investigation or to
other persons, agencies, or entities.
•
I am also aware of the obligations of OCR to honor requests under the Freedom
of Information Act (FOIA). I understand that it may be necessary for OCR to
disclose information, including personally identifying information, which it has
gathered as part of its investigation of my complaint.
Complaint Consent Form
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HHS-700 (10/17) (BACK)
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