"Health Information Privacy Complaint Form" - Delaware

This fillable "Health Information Privacy Complaint Form" is a document issued by the Delaware Health and Social Services specifically for Delaware residents.

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Download "Health Information Privacy Complaint Form" - Delaware

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HEALTH INFORMATION PRIVACY COMPLAINT
Person’s whose rights where violate:
Your First Name:
Your Last Name:
Street Address:
City:
State:
Zip:
Home Phone Number:
Email Address:
☐Yes
☐ No
Are you filing this complaint for someone else?
If yes, please write your first and last name.
First Name:
Last Name:
Who (or what agency or organization, e.g., provider) do you believe violated your (or someone
else’s) health information privacy rights or committed another violation of the Privacy Rule?
Person/ Agency:
Street Address:
City:
State:
Zip:
Phone Number:
When do you believe that the violation of health information privacy rights occurred? List date(s)
____________________________________________________________________________________
According to the HIPAA Privacy notice 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):
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________
_____________________
Signature
Date (mm/dd/yyyy)
HEALTH INFORMATION PRIVACY COMPLAINT
Person’s whose rights where violate:
Your First Name:
Your Last Name:
Street Address:
City:
State:
Zip:
Home Phone Number:
Email Address:
☐Yes
☐ No
Are you filing this complaint for someone else?
If yes, please write your first and last name.
First Name:
Last Name:
Who (or what agency or organization, e.g., provider) do you believe violated your (or someone
else’s) health information privacy rights or committed another violation of the Privacy Rule?
Person/ Agency:
Street Address:
City:
State:
Zip:
Phone Number:
When do you believe that the violation of health information privacy rights occurred? List date(s)
____________________________________________________________________________________
According to the HIPAA Privacy notice 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):
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________
_____________________
Signature
Date (mm/dd/yyyy)
The remaining information on this form is optional. Failure to answer these voluntary questions will not
affect DDDS decision to process your complaint.
Do you need special accommodations for DDDS to communicate with you about this complaint?
(check all that apply)
☐Braille
☐Large Print
☐ TDD
☐ Sign Language Interpreter
☐Foreign Language (specify language):
_______________________
☐Other: ______________________________________
Have you filed your complaint anywhere else? If so, please provide the following:
Person/ Agency/ Court:
Dates Filed:
Case Numbers:
Please send all complaints to:
Stockley Center
Attention: HIPAA Privacy/Complaints Officer
26351 Patriots Way
Georgetown, DE 19947
Filing a complaint with DDDS is voluntary. However, without the information requested, DDDS 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 process your complaint. Information submitted on this form is
treated confidentially and is protected under the provision of the Privacy Act of 1974.
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