Form Hhs 758 PDF Details

If you are a homeowner, then you know that there is always something that needs to be fixed or improved on your property. Whether it is the roof, the windows, the driveway, or the fence, there are always projects to undertake. And if you are like most people, you probably don't have the time or expertise to do all of those projects yourself. That is where home improvement contractors come in. Contractors can help you with a wide variety of home improvement projects, big and small. But how do you know which contractor to choose? One way to find a reputable contractor is to use Form HHS 758. This form can help you find qualified contractors who meet certain standards set by the government. So if you are planning on hiring a contractor for any home improvement project, be sure to fill out Form HHS 758 first.

QuestionAnswer
Form NameForm Hhs 758
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespscomplaintform patient safety confidentiality complaint form

Form Preview Example

Form Approved: OMB No. 0935-0143 See OMB Statement on page 2.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office for Civil Rights (OCR)

PATIENT SAFETY CONFIDENTIALITY COMPLAINT

Your First Name

Your Last Name

Home Phone (Please include area code)

Work Phone (Please include area code)

Street Address

City

State

ZIP

E-Mail Address (If available)

Who is the patient, provider or reporter who is identified in the information you believe was impermissibly disclosed?

First Name or Business Name

Last Name (Leave blank if using Business Name to left)

Who (e.g., provider, patient safety organization, other person) do you believe disclosed patient safety work product in violation of patient safety confidentiality?

Person/Agency/Organization

Street Address

City

State

ZIP

Phone

When do you believe that the impermissible disclosure occurred?

List Date(s)

Describe briefly what happened. How and why do you believe a person or organization impermissibly disclosed patient safety work product? Please be as specific as possible. Why do you believe the information disclosed is patient safety work product? (Attach additional pages as needed)

Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.

Signature

Date (mm/dd/yyyy)

Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your complaint. We collect this information under the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). We use it to investigate your complaint to see whether enforcement action is appropriate. The Privacy Act of 1974 protects the information submitted on this form. We may share your information with the Department of Justice or a court in the event of a lawsuit, with another agency that has jurisdiction over potential violations or reviews certifications of Patient Safety Organizations, or with others who help us carry out our work. Otherwise, OCR will not share your name or other identifying information about you unless you agree. You are not required to use this form. You may write a letter or submit a complaint electronically with the same information. You will find directions for submitting an electronic complaint on our web site at http://hhs.gov/ocr/privacy/psa/complaint/index.html. To mail a complaint see reverse page for OCR address.

HHS-758 (11/08)

PAGE 1 OF 2

PSC Graphics (301) 443-1090 EF

The remaining information on this form is optional. Failure to answer these voluntary

questions will not affect OCR's decision to process your complaint.

Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)

Braille

Large print

Cassette tape

Computer diskette

Electronic Mail

TDD

Sign language interpreter (Specify language):

Foreign language interpreter (Specify language):

Other (Specify):

To help us better serve you, answer the following question.

HOW DID YOU LEARN ABOUT THE OFFICE FOR CIVIL RIGHTS?

HHS Website / Internet Search

Family / Friend / Associate

Religious / Community Org

Lawyer / Legal Org

Phone Directory

Employer

Fed / State / Local Gov

Healthcare Provider / Health Plan

Conference / OCR Brochure

Other (Specify):

If we cannot reach you directly, is there someone we can contact to help us reach you?

First Name

Last Name

Home Phone (Please include area code)

Work Phone (Please include area code)

Street Address

City

State

ZIP

E-Mail Address (If available)

Have you filed your complaint anywhere else? If so, please provide the following: (Attach additional pages as needed)

Person / Agency / Organization / Court Name(s)

Date(s) Filed

Case Number(s) (If known)

To mail a complaint, please type or print, and return completed complaint to:

Office for Civil Rights

Department of Health and Human Services

Attn: Patient Safety Act

200 Independence Ave., SW, Rm. 509F

Washington, DC 20201

(202)619-0403

TDD 1-800-537-7697 FAX: (202) 619-3818

To submit an electronic complaint, see our web site at http://hhs.gov/ocr/privacy/psa/complaint/index.html.

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 20 minutes per response, including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201.

HHS-758 (11/08)

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The right way to fill in Form Hhs 758 part 1

2. After this part is done, go on to type in the applicable information in all these - Describe briefly what happened How, Please sign and date this, Signature, Date mmddyyyy, and Filing a complaint with OCR is.

A way to fill out Form Hhs 758 step 2

3. Completing Do you need special accommodations, Braille, Large print, Cassette tape, Computer diskette, Electronic Mail, TDD, Sign language interpreter Specify, Foreign language interpreter, Other Specify, To help us better serve you answer, HOW DID YOU LEARN ABOUT THE OFFICE, HHS Website Internet Search, Family Friend Associate, and Religious Community Org is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Find out how to prepare Form Hhs 758 part 3

Regarding Large print and Computer diskette, ensure that you do everything right in this current part. Both these are the most significant ones in this document.

4. To go ahead, this next section requires filling out several form blanks. Examples of these are State, ZIP, EMail Address If available, Have you filed your complaint, Person Agency Organization, Dates Filed, Case Numbers If known, To mail a complaint please type or, Office for Civil Rights, Department of Health and Human, Attn Patient Safety Act, Independence Ave SW Rm F, Washington DC, TDD FAX, and To submit an electronic complaint, which you'll find crucial to continuing with this particular process.

The way to fill out Form Hhs 758 stage 4

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