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Health Information Privacy Complaint - Massachusetts
| Health Information Privacy Complaint Form. This is a Massachusetts form and can be used in General Statewide . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved: OMB No. 0990-0269. See OMB Statement on Reverse. OFFICE FOR CIVIL RIGHTS (OCR) HEALTH INFORMATION PRIVACY COMPLAINT YOUR FIRST NAME YOUR LAST NAME HOME PHONE (Please include area code) WORK PHONE (Please include area code) STREET ADDRESS CITY STATE ZIP E-MAIL ADDRESS (If available) Are you filing this complaint for someone else? Yes No If Yes, whose health information privacy rights do you believe were violated? FIRST NAME LAST NAME Who (or what agency or organization, e.g., provider, health plan) do you believe violated your (or someone else's) health information privacy rights or committed another violation of the Privacy Rule? PERSON / AGENCY / ORGANIZATION STREET ADDRESS CITY STATE ZIP PHONE (Please include area code) When do you believe that the violation of health information privacy rights occurred? LIST DATE(S) Describe briefly what happened. 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) Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature. SIGNATURE DATE (mm/dd/yyyy) Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your complaint. We collect this information under authority of the Privacy Rule issued pursuant to the Health Insurance Port ability and Accountability Act of 1996. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible health information privacy violations, for internal systems operations, or for routine uses, which include disclosure of information outside the Department for purposes associated with health information privacy compliance and as permitted by law. It is illegal for a covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the Privacy Rule. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information. To submit an electronic complaint, go to OCR's Web site at: www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. To mail a complaint see reverse page for OCR Regional addresses. HHS-700 (7/09) (FRONT) PSC Graphics (301) 443-1090 EF American LegalNet, Inc. www.FormsWorkFlow.com 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 OCR to communicate with you about this complaint? (Check all that apply) Braille Large Print Cassette tape Computer diskette Electronic mail TDD Sign language interpreter (specify language): Foreign language interpreter (specify language): Other: If we cannot reach you directly, is there someone we can contact to help us reach you? FIRST NAME HOME PHONE (Please include area code) STREET ADDRESS STATE ZIP LAST NAME WORK PHONE (Please include area code) CITY E-MAIL ADDRESS (If available) Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed) PERSON / AGENCY / ORGANIZATION / COURT NAME(S) DATE(S) FILED CASE NUMBER(S) (If known) To help us better serve the public, please provide the following information for the person you believe had their health information privacy rights violated (you or the person on whose behalf you are filing). ETHNICITY (select one) Hispanic or Latino Not Hispanic or Latino RACE (select one or more) American Indian or Alaska Native Black or African American Asian White Native Hawaiian or Other Pacific Islander Other (specify): PRIMARY LANGUAGE SPOKEN (if other then English) How did you learn about the Office for Civil Rights? HHS Website/Internet Search Fed/State/Local Gov Family/Friend/Associate Religious/Community Org Lawyer/Legal Org Other (specify): Phone Directory Employer Healthcare Provider/Health Plan Conference/OCR Brochure To mail a complaint, please type or print, and return completed complaint to the OCR Regional Address based on the region where the alleged violation took place. If you need assistance completing this form, contact the appropriate region listed below. Region I - CT, ME, MA, NH, RI, VT Office for Civil Rights, DHHS JFK Federal Building - Room 1875 Boston, MA 02203 (617) 565-1340; (617) 565-1343 (TDD) (617) 565-3809 FAX Region II - NJ, NY, PR, VI Office for Civil Rights, DHHS 26 Federal Plaza - Suite 3313 New York, NY 10278 (212) 264-3313; (212) 264-2355 (TDD) (212) 264-3039 FAX Region III - DE, DC, MD, PA, VA, WV Office for Civil Rights, DHHS 150 S. Independence Mall West - Suite 372 Philadelphia, PA 19106-3499 (215) 861-4441; (215) 861-4440 (TDD) (215) 861-4431 FAX Region IV - AL, FL, GA, KY, MS, NC, SC, TN Office for Civil Rights, DHHS 61 Forsyth Street, SW. - Suite 3B70 Atlanta, GA 30303-8909 (404) 562-7886; (404) 331-2867 (TDD) (404) 562-7881 FAX Region V - IL, IN, MI, MN, OH, WI Office for Civil Rights, DHHS 233 N. Michigan Ave. - Suite 240 Chicago, IL 60601 (312) 886-2359; (312) 353-5693 (TDD) (312) 886-1807 FAX Region VI - AR, LA, NM, OK, TX Office for Civil Rights, DHHS 1301 Young Street - Suite 1169 Dallas, TX 75202 (214) 767-4056; (214) 767-8940 (TDD) (214) 767-0432 FAX Region VII - IA, KS, MO, NE Office for Civil Rights, DHHS 601 East 12th Street - Room 248 Kansas City, MO 64106 (816) 426-7277; (816) 426-7065 (TDD) (816) 426-3686 FAX Region VIII - CO, MT, ND, SD, UT, WY Office for Civil Rights, DHHS 1961 Stout Street - Room 1426 Denver, CO 80294 (303) 844-2024; (303) 844-3439 (TDD) (303) 844-2025 FAX Region X - AK, ID, OR, WA Office for Civil Rights, DHHS 2201 Sixth Avenue - Mail Stop RX-11 Seattle, WA 98121 (206) 615-2290; (206) 615-2296 (TDD) (206) 615-2297 FAX Region IX - AZ, CA, HI, NV, AS, GU, The U.S. Affiliated Pacific Island Jurisdictions Office for Civil Rights, DHHS 90 7th Street, Suite 4-100 San Francisco, CA 94103 (415) 437-8310; (415) 437-8311 (TDD) (415) 437-8329 FAX
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