At some point, you may find yourself feeling like your privacy has been violated. Whether it's by a particular organization or person, it can be difficult to know how to proceed. Fortunately, most governments and organizations provide options for filing formal complaints about an individual’s right to privacy being infringed upon. Filling out a Privacy Complaint Form is one such option – this post will walk you through what information you should include in the form and when and where it should be submitted.
| 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)
Telephone (Home) |
|
|
Telephone (Work) |
|
|
|
|
|
|
Street Address |
|
|
|
City |
|
|
|
|
|
State |
Zip |
|
||
|
|
|
|
|
Are you filing this claim for someone else? |
Yes |
No |
||
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)