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
Complaint Filing Form & Fact Sheet are also available in Microsoft Word and Adobe PDF format.
If you have questions about this form, please contact the
HIPAA Privacy Officer at 834-5172.
Instructions:
Click inside the boxes below, fill out all necessary information.
Click the SUBMIT button at the bottom of this page to send your request to the County of Orange HIPAA Privacy Officer.
YOUR INFORMATION
First name:
Middle initial:
Street address:
City:
State:
Zip Code:
Email address:
replace with your own address
Daytime phone number (with area code):
Evening phone number (with area code):
Best way to reach you:
Best hours to reach you:
EMPLOYEES ONLY - Employees may file complaints anonymously
Unit title:
Supervisor's name:
CONSENT TO DISCLOSE YOUR NAME
Please select one of the following:
I consent to my name being disclosed to investigate this complaint. We will not divulge information about you in our investigation within the limits allowed in law.
I do not consent to my name being disclosed. Not using your name may hinder our ability to complete the investigation.
INFORMATION ABOUT YOUR COMPLAINT
Name of the organization your complaint is against:
Name of the person your complaint is against:
Date you first noticed action or believe a violation of health information privacy rights occurred:
Date(s) action(s) occurred:
Are you filing this complaint for someone else? Yes
No
If yes, name of person whose health information privacy rights you believe were violated:
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 personal health information.
The organization/person has inappropriately used my personal health information.
The organization/person has inappropriately disposed of my personal health information.
The organization/person has denied access to my personal health information.
The organization/person has denied my amendment to my personal health information.
The organization's privacy policies and procedures violate HIPAA requirements.
Please provide a detailed description of your complaint covering what, when, who, how, where, and if you know, why about what happened. Please be specific about the time and date of the incident, if applicable.
Do you have witness(es):
no yes
If yes, please provide the names, addresses and telephone numbers of your witness(es) below:
Witness name:
Witness address:
Witness phone:
Witness name:
Witness address:
Witness phone:
RESOLUTION OF YOUR COMPLAINT
Please describe how your privacy complaint could be resolved:
*Please make sure all information provided above is correct. When finished press the "SUBMIT" button and your request will be automatically sent to the County of Orange Privacy Officer.
Filing a complaint with the County of Orange HIPAA Privacy Officer is voluntary. However, without the information requested above, the Privacy Officer may be unable to proceed with your complaint. We collect this information under 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 this form. You also may write a letter or submit a complaint electronically with the same information.
