The HIPAA Privacy Rule allows individuals to file complaints regarding potential violation of their privacy rights by a covered entity. If you believe that a person, agency, or program covered under the County of Orange hybrid-entity or its contractor violated your or someone else’s health information privacy rights, or committed another HIPAA Privacy Rule violation, you may file a complaint by submitting the form below. The County of Orange can only review and investigate complaints that fall within its hybrid-entity covered components and contractors. These covered components operate under the County’s jurisdiction to protect client privacy and ensure compliance with federal HIPAA standards.
The information you provide here will remain confidential to the extent possible. However, we may need to divulge information to investigate your claim. Anyone may file a complaint. Members of the workforce may use this form to report violations of HIPAA by others in the workforce. The Privacy and Security Complaint Form Guide is available in Adobe PDF format.
If you have questions about this form, please contact the County Privacy Officer.
Instructions:
Filing a complaint with the County of Orange Privacy Officer is voluntary. However, without the information requested, the Privacy Officer may be unable to proceed with your complaint.
We collect this information under the authority of the Privacy Rule issued pursuant to the Health Insurance Portability and Accountability Act of 1996. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially.
Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible health information privacy violations, for internal systems operations, or for routine uses, which include disclosure of information outside the Privacy Office for purposes associated with health information privacy compliance and as permitted by law.
It is illegal for a covered entity to intimidate, threaten, coerce, discriminate, or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the Privacy Rule. You are not required to use the county form. You also may write a letter or submit a complaint electronically with the same information.
