Fill and Sign the Health Information Form

Health Information Privacy Complaint Form Patient Name: __________________________________________________________ Date: ____________ Patient Identifier Number: _________________ Street Address: __________________________________________________________ City: _________________ State: _________________ Zip Code: ______________ Please describe the nature of the complaint: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of Occurrence: ____________ Information Affected: ____________ List possible recipients of health information: Name: Organization:_____________________ _____________________ _____________________ __________________________________________ _____________________ Patient Signature:_________________________________________________________ Date: ____________Please mail this information to:HIPPA Privacy Officer {Insert Name of Company} {Insert Street Address} {Insert City, State, and Zip Code}