Privacy And Security Complaint Form

INDIVIDUAL FILING COMPLAINT

name

First

Middle

Last

address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Daytime Telephone Number (Required)

E-mail Address

Best Hours to Reach You

Are you filing this complaint on behalf of someone else?

Yes

If yes, who’s privacy rights do you believe were violated?

Please select one of the following

I consent to my name being disclosed to investigate this complaint.

I do not consent to my name being disclosed. Please note that not using your name may hinder, limit, or delay our ability to investigate this complaint.

INFORMATION ABOUT YOUR COMPLAINT

Name of organization your complaint is against:

Name of person your complaint is against:

Date(s) Action(s)/violation(s) Occurred:

Address

Phone number

Details of the complaint: I have reason to believe that one or more of the following has occurred:

The organization/person has inappropriately disclosed my information or other confidential personal information.

The organization has inappropriately used my information or other confidential personal information.

The organization/person has inappropriately disposed of my information or other confidential personal information.

The organization/person has denied me or my personal representative access to my information or other confidential personal information.

The organization/person has denied my request to amend my information or other confidential personal information.

The organization’s privacy policies and procedures violate the law.

Please provide a detailed description of your complaint covering what, when, who, how, where, and why. You may attach additional pages if there is not enough space here:

Do you have witness(es)?

Yes

Witness Name:

Address:

Telephone Number:

Witness Name:

Address:

Telephone Number:

Witness Name:

Address:

Telephone Number:

YOUR SIGNATURE

I certify that the information on this form is true and correct to the best of my information, knowledge, and belief.

Signature

Date

Filing a complaint is voluntary. However, without the information requested above, we may not be able to proceed with your complaint. We will use the information to evaluate your complaint and determine how we will process your complaint. Information submitted on this form is treated as confidential. Names or other identifying information about individuals are disclosed when it is necessary to investigate possible health information privacy violations, internal systems operations, or routine uses. This can include disclosure of information outside the Department for purposes associated with health information privacy compliance and as required or permitted by law. It is illegal for a covered entity to intimidate, threaten, coerce, discriminate, or retaliate against you for filing this complaint. You are not required to use this form. You may also write a letter or submit a complaint electronically with the same information to us.

Privacy And Security Complaint Form

INDIVIDUAL FILING COMPLAINT

CONSENT TO DISCLOSE YOUR NAME

INFORMATION ABOUT YOUR COMPLAINT

YOUR SIGNATURE