Get Privacy Complaint Form Case No See Other Side For - Oasas Ny

This guide will assist you in completing the Privacy Complaint Form from the New York State Office of Alcoholism and Substance Abuse Services. By following these steps, you can effectively submit your privacy complaint online.

Follow the steps to fill out the Privacy Complaint Form accurately.

1. Click the ‘Get Form’ button to obtain the Privacy Complaint Form and open it in your preferred editing program.
2. Start by entering the patient’s last name, first name, and middle initial in the designated fields. This information identifies the individual filing the complaint.
3. Next, fill in the case number, facility name, and unit to ensure your complaint is linked to the correct location and context.
4. In the 'Description of Complaint' section, provide a clear and concise account of the privacy issue, detailing what information you believe was improperly used or disclosed, and by whom.
5. State the action you would like to be taken regarding your complaint. Be specific to ensure your concerns are addressed appropriately.
6. Sign and date the form in the designated areas. If the signature of a parent or guardian is required, they should also provide their signature and print their name.
7. Ensure that a copy of the completed form is given to the patient and prepare an additional copy for the patient's case record.
8. Once the form is fully completed, you may choose to save any changes, download, print, or share the form as necessary.

Complete your Privacy Complaint Form online today to ensure your rights are protected.