Fill and Sign the S E E Omb Statement on Reverse Form

If y o u h ave q uestio ns a b out t h is f o rm , c all O CR ( to ll- fr e e) a t: 1 -8 00-3 68-1 019 ( a n y l a n guag e) o r 1 -8 00-5 37-7 697 ( T D D) A re y o u f ilin g t h is c o m pla in t f o r s o m eo ne e ls e? Yes NoIf Y es, w hose h ealt h in fo rm atio n p riv a cy r ig hts d o y o u b elie ve w ere v io la te d?FIR ST N AM E LA ST N AM EW ho ( o r w hat a g en cy o r o rg an iz a tio n, e .g ., p ro vid er, h ealt h p la n ) d o y o u b elie ve v io la te d y o ur ( o r s o m eo ne e ls e’s ) h ealt h in fo rm atio n p riv acy r ig hts o r c o m mit te d a n oth er v io la tio n o f t h e P riv acy R ule ?P E R SO N / A G EN C Y / O RG AN IZ A TIO NW hen d o y o u b elie ve t h at t h e v io la tio n o f h ealt h i n fo rm atio n p riv acy r ig hts o ccu rre d ?LIS T D ATE (S ) D escrib e b rie fly w hat h ap pen ed . H ow a n d w hy d o y o u b elie ve y o ur ( o r s o m eo ne e ls e’s ) h ealt h i n fo rm atio n p riv acy r ig h ts w ere vio la te d , o r t h e p riv acy r u le o th erw is e w as v io la te d ? P le ase b e a s s p ecif ic a s p ossib le . ( A tta ch a ddit io nal p ages a s n eeded) P le ase s ig n a n d d ate t h is c o m pla in t.F ilin g a c o m pla in t w it h O CR is v o lu nta ry . H ow eve r, w it h out th e in fo rm atio n r e queste d a bove , O CR m ay b e u nable to p ro ce ed w it h y o ur co m pla in t. W e c o lle ct th is in fo rm atio n u nder a uth orit y o f th e P riv a cy R ule is su ed p urs u ant to th e H ealt h In su ra nce P orta bilit y a nd Acco u nta bilit y A ct o f 1 996. W e w ill u se th e in fo rm atio n y o u p ro vid e to d ete rm in e if w e h ave ju ris d ic tio n a nd, if s o , h ow w e w ill p ro ce ss yo ur c o m pla in t. In fo rm atio n s u bm it te d o n th is fo rm is tr e ate d c o nfid entia lly a nd is p ro te cte d u nder th e p ro vis io ns o f th e P riv a cy A ct o f 19 74. N am es o r o th er id entif y in g in fo rm atio n a bout in div id ua ls a re d is clo se d w hen it is n ece ssa ry fo r in ve stig atio n o f p oss ib le h ealt h in fo rm atio n p riv a cy v io la tio ns, fo r in te rn al s yste m s o pera tio ns, o r fo r ro utin e u se s, w hic h in clu de d is clo su re o f in fo rm atio n o uts id e th e De p artm ent fo r p urp ose s a sso cia te d w it h h ealt h in fo rm atio n p riv a cy c o m plia nce a nd a s p erm it te d b y la w . It is ille gal fo r a c o ve re d entit y to in tim id ate , th re ate n, c o erc e , d is crim in ate o r re ta lia te a gain st y o u fo r filin g th is c o m pla in t o r fo r ta kin g a ny o th er a ctio n to enfo rc e y o ur rig hts u nder th e P riv a cy R ule . Y ou a re n ot re qu ir e d to u se th is fo rm . Y ou a ls o m ay w rit e a le tte r o r s u bm it a c o m pla in t ele ctr o nic a lly w it h t h e s a m e in fo rm atio n. T o s u bm it a n e le ctr o n ic c o m pla in t, g o t o o ur w eb s it e a t:w w w.h hs.g ov/o cr/p riv acyh ow to file .h tm l . T o m ail a c o m pla in t s e e r e ve rs e p age f o r O CR R egio nal a ddre sse s. D EPA RTM EN T O F H EA LTH A ND H UM AN S ER VIC ES OF FIC E F O R C IV IL R IG HTS ( O CR) HE A LTH IN FO RM ATIO N P R IV A CY C O M PLA IN T Form A ppro ve d: O M B N o. 0 990-0 269. Se e O M B S ta te m ent o n R eve rs e .H H S-7 00 ( 1 /0 3) ( F R O NT) (The remaining information on this form is optional. Failure to answer these voluntary questions will not affect OCR’s decision to process your complaint.)Do you need special accommodations for us to communicate with you about this complaint (check all that apply)?If we cannot reach you directly, is there someone we can contact to help us reach you?Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed.)P E R SO N / A G EN C Y / O RG AN IZ A TIO N / C O URT N AM E(S )To help us better serve the public, please provide the following information for the person you believe had their health infor mation privacy rights violated (you or the person on whose behalf you are filing).ETH NIC IT Y (select one) RAC E (select one or more)H is p a nic o r L atin o Am eric a n In dia n o r A la ska N ativ e Asia n Nativ e H aw aiia n o r O th er P acif ic Is la nderTo mail a complaint, please type or print, and return completed complaint to the OCR Regional Address based on the region where the alledged violation took place.Burd en S ta te m en t P ublic r e portin g b urd en fo r th e c o lle ctio n o f in fo rm atio n o n th is B ra ille Larg e P rin t Casse tte ta pe Com pute r d is ke tte Ele ctr o nic m ail TD D Sign language interpreter (s p ecif y la ng uage):F ore ig n la nguage in te rp re te r (specify language): _____________________________________________ ____________________________ ______________________________________________________O th er:H H S-7 00 ( 4 /2 ) ( B AC K) co m pla in t fo rm is e stim ate d to a ve ra ge 4 5 m in ute s p er r e sp onse , in clu d in g th e tim e fo r r e vie w in g in str u ctio ns, g ath erin g th e d ata n eeded a nd e nte rin g a nd revie w in g th e in fo rm atio n o n th e c o m ple te d c o m pla in t fo rm . A n a gency m ay n ot c o nduct o r s p onso r, a nd a p ers o n is n ot r e quir e d to r e sp ond to , a c o lle ctio n of in fo rm atio n u nle ss it d is p la ys a v a lid c o ntr o l n um ber. S end c o m ments r e gard in g th is b urd en e stim ate o r a ny o th er a sp ect o f th is c o lle ctio n o f in fo rm atio n, in clu din g s u ggestio ns fo r r e ducin g th is b urd en, to : H HS/O S R eports C le a ra nce O ffic e r, O ffic e o f In fo rm atio n R eso urc e s M anagem ent, 2 00 In dependence Ave . S .W ., R oom 5 31 H , W ash in gto n, D .C . 2 0201.