"Complaint Form Regarding Handling of Protected Health Information" - Delaware

This fillable "Complaint Form Regarding Handling of Protected Health Information" is a document issued by the Delaware Department of Human Resources specifically for Delaware residents.

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Download "Complaint Form Regarding Handling of Protected Health Information" - Delaware

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STATE OF DELAWARE
COMPLAINT F
REGARDING H
O
P
H
I
ORM
ANDLING
F
ROTECTED
EALTH
NFORMATION
This Form is used by individuals to register complaints concerning the handling of their protected health information (“PHI”) in the
possession of the health care plans sponsored or maintained by State of Delaware and any of its affiliates, or the business associates
of such plans. Submit this Completed Form to the Statewide Benefits Office (SBO) by secure email (benefits@state.de.us),
fax (302-739-8339) or mail (97 Commerce Way, Suite 201, Dover, DE 19904). Federal law prohibits State of Delaware, its
affiliates, and business associates from retaliating against you for filing this complaint.
COMPLAINANT:
Name:
(Print name, addresses,
Mailing Address:
telephone number and
Email Address:
date)
Telephone number:
Date:
NATURE OF
Please describe your complaint. Please be as specific as you can with respect to the details, including names of persons
COMPLAINT:
involved (if known), dates, locations, and specific actions or omissions. Write on the back of this sheet, or attach
additional sheets, if necessary.
For office use only:
Receipt:
Date: ___________ Recipient name: ________________________________ Date delivered to Privacy Official/ Deputy: __________
Investigation:
The Privacy Official or his or her designee must investigate this complaint. The investigation should be documented, and its
conclusions reduced to writing. Where warranted, the Privacy Official should direct appropriate remedial action, and impose
appropriate sanctions.
Report to Complainant:
The results of the investigation (whether the complaint should prove unfounded or accurate) should be communicated to the
complainant (sanctions against persons or other entities need not be revealed).
Complainant notified: (insert date): _________________
Privacy Official/Deputy Privacy Official certification: Initial here: _______ Date: ______________
Keep a copy of this Form
STATE OF DELAWARE
COMPLAINT F
REGARDING H
O
P
H
I
ORM
ANDLING
F
ROTECTED
EALTH
NFORMATION
This Form is used by individuals to register complaints concerning the handling of their protected health information (“PHI”) in the
possession of the health care plans sponsored or maintained by State of Delaware and any of its affiliates, or the business associates
of such plans. Submit this Completed Form to the Statewide Benefits Office (SBO) by secure email (benefits@state.de.us),
fax (302-739-8339) or mail (97 Commerce Way, Suite 201, Dover, DE 19904). Federal law prohibits State of Delaware, its
affiliates, and business associates from retaliating against you for filing this complaint.
COMPLAINANT:
Name:
(Print name, addresses,
Mailing Address:
telephone number and
Email Address:
date)
Telephone number:
Date:
NATURE OF
Please describe your complaint. Please be as specific as you can with respect to the details, including names of persons
COMPLAINT:
involved (if known), dates, locations, and specific actions or omissions. Write on the back of this sheet, or attach
additional sheets, if necessary.
For office use only:
Receipt:
Date: ___________ Recipient name: ________________________________ Date delivered to Privacy Official/ Deputy: __________
Investigation:
The Privacy Official or his or her designee must investigate this complaint. The investigation should be documented, and its
conclusions reduced to writing. Where warranted, the Privacy Official should direct appropriate remedial action, and impose
appropriate sanctions.
Report to Complainant:
The results of the investigation (whether the complaint should prove unfounded or accurate) should be communicated to the
complainant (sanctions against persons or other entities need not be revealed).
Complainant notified: (insert date): _________________
Privacy Official/Deputy Privacy Official certification: Initial here: _______ Date: ______________
Keep a copy of this Form
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