If you believe that your health privacy rights – or the health privacy rights of someone else -- have been violated, the Federal HIPAA Privacy Rule allows you to file a complaint.  

The person, agency, or program must be covered under the HIPAA rules. To file your complaint, please complete and submit the form below. 
 
Will my information be confidential? The information you provide will remain confidential to the extent possible. However, we may need to divulge information to investigate your claim.  

Who can file a complaint? Any individual may file a complaint. Members of the workforce may use this form to report violations of HIPAA by others in the workforce. 

How do I fill out the form?  

Instructions: 

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

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 County Privacy Officer at (714) 834-4082. 

Important additional information to know before filing:

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 the 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.