The Privacy Complaint Form serves as a critical tool for individuals seeking to report violations of their privacy rights or breaches of the Privacy Rule and specific privacy policies by the entities under the Harris County Hospital District (HCHD). Located in Houston, Texas, the Office of Privacy Administration provides a clear avenue for complaints, ensuring that individuals can easily address concerns regarding the mishandling of Protected Health Information (PHI). This form seeks detailed information, including the complainant's contact details, the identity of the person (if filing on behalf of someone else), and a comprehensive account of the alleged violation, including who or which facility is believed to be responsible, and the nature and timing of the supposed breach of privacy. It emphasizes the voluntary nature of filing a complaint but notifies the complainant that insufficient information may hinder the processing of their complaint. The information collected through this form is treated with utmost confidentiality and is used strictly for investigating possible violations, operational purposes, and when legally required. Additionally, it reassures the complainant against any form of retaliation by the HCHD or other entities for enforcing their rights under the Privacy Rule, a cornerstone provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This form is a testament to the legal and ethical commitment to protecting individual privacy and the measures in place to address any grievances effectively.
| Question | Answer |
|---|---|
| Form Name | Privacy Complaint Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | harris county hospital complaint, medicare complaint form, complaint forms online, patient complaint form pdf |
Office of Privacy Administration
2525 Holly Hall
P.O. Box 300033
Houston, TX 77054
PRIVACY COMPLAINT FORM
If you have any questions about this form, call HCHD Office of Privacy Administration at:
Name (Last, First, MI)
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Are you filing this claim for someone else? |
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If the complaint is regarding someone else, please provide his/her: Name (Last, First, MI)
Who (or what HCHD facility) do you believe violated your (or another’s) rights for privacy of Protected Health Information (PHI), or violated other parts of the Privacy Rule or HCHD privacy policies.
Person:Location/Facility:
When do you believe the violation occurred?
How and/or why do you believe your (or another’s) privacy rights, the Privacy Rule or HCHD privacy policies were violated? If you are complaining about a HCHD privacy policy, please use this space.
Please Sign and Date this Complaint
Signature
Date
Filing a complaint with the HCHD Office of Privacy Administration (OPA) is voluntary. However, without the information requested above, OPA 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 on this form is treated confidentially. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible violations regarding PHI, for internal operations and for disclosures required by law. It is illegal for the Hospital District or any other covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or taking any other action to enforce your rights under the Privacy Rule. Please submit the complaint to the address in the upper right hand corner.
282015(05/03)