HIPAA Complaint Filing Form

The information you provide here will remain confidential to the extent possible. However we may need to divulge information to investigate your claim. Anyone may file a complaint. Members of the workforce may use this form to report violations of HIPAA by others in the workforce. The Complaint Filing Form & Fact Sheet are also available in Microsoft Word and Adobe PDF format.

If you have questions about this form, please contact the Deputy County Privacy Office at 834-5172.
Instructions:

  • Click inside the boxes below, fill out all necessary information.
  • Click the SUBMIT button at the bottom of this page to send your request to the County of Orange Deputy County Privacy Office.


Filing a complaint with the County of Orange Privacy Officer is voluntary. However, without the information requested below, the Privacy Officer 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 will process your complaint. Information submitted on this form is treated confidentially. 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 Privacy Office 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.
HIPAA Complaint Filing Form

1. Your Information












EMPLOYEES ONLY - Employees may file complaints anonymously


2. Consent to Disclose Your Name

I consent to my name being disclosed to investigate this complaint. We will not divulge information about you in our investigation within the limits allowed in law.
I do not consent to my name being disclosed. Not using your name may hinder our ability to complete the investigation.

3. Information About Your Complaint



Yes
No

Details of the Complaint:
The organization/person has inappropriately disclosed my personal health information.The organization/person has inappropriately used my personal health information.The organization/person has inappropriately disposed of my personal health information.
The organization/person has denied access to my personal health information.The organization/person has denied my amendment to my personal health information.The organization's privacy policies and procedures violate HIPAA requirements.
YesNo
If yes, please provide the names, addresses and telephone numbers of your witness(es) below:




4. Resolution of Your Complaint

*Please make sure all information provided above is correct. When finished press the "SUBMIT" button and your request will be automatically sent to the County of Orange Privacy Officer.
  Please enter the word above in the space below