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Test Privacy Complaint Form

Test Privacy Complaint Form

Use a privacy complaint form template to make your document workflow more streamlined.

Applicable Patient s address if known Date of the incident that is the reason for this complaint Please give a brief explanation of your complaint including dates and names/addresses of other people who may be involved. Include copies of relevant material you may have. Privacy Complaint Form Please use this form to submit a complaint concerning the privacy and confidentiality of patient protected health information. You may also file a complaint with the U.S. Department of Health and Human...
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