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Get and Sign Penn State Privacy Office Form
Federal Privacy Rule?
Person and/or Department
Name:
Campus
When do you believe that the violation of health information privacy rights occurred?
List date(s)
Describe briefly what happened. How and why do you believe your (or someone else’s) health
information privacy rights were violated, or the privacy rule otherwise was violated? Please be as
specific as possible. (Attach additional pages as needed.)
Please sign and date this complaint.
Signature
Date
Please mail this form to: Penn State...
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