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HIPAA COMPLAINT

As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), you have a right to file a complaint about our privacy policies, procedures and/or actions. The Department will not engage in any discriminatory or other retaliatory behavior against you because of this complaint. Please be as thorough and forthright as possible.

Health Information Complaint Form

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This field is for validation purposes and should be left unchanged.
Name*
Please be as specific as possible with dates, times and the specific policy, procedure or action taken. Include the names, if any, of any one in the office with whom you discussed this.
Consent*
By signing above, I acknowledge that the information provided is accurate and complete to the best of my knowledge.