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Get TX Privacy Complaint Form 2003-2024

We will use the information you provide to determine if we have jurisdiction and if so how we will process your complaint. Information on this form is treated confidentially. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible violations regarding PHI for internal operations and for disclosures required by law. It is illegal for the Hospital District or any other covered entity to intimidate threaten coerce discriminate or retaliate against you for filing this complaint or taking any other action to enforce your rights under the Privacy Rule. Office of Privacy Administration 2525 Holly Hall P. O. Box 300033 Houston TX 77054 PRIVACY COMPLAINT FORM If you have any questions about this form call HCHD Office of Privacy Administration at 713-566-6097 Name Last First MI Telephone Home Telephone Work Street Address State City Zip Are you filing this claim for someone else E-Mail Address If Available Yes No If the complaint is regarding someone else please provide his/her Name Last First MI Who or what HCHD facility do you believe violated your or another s rights for privacy of Protected Health Information PHI or violated other parts of the Privacy Rule or HCHD privacy policies. Person Location/Facility When do you believe the violation occurred How and/or why do you believe your or another s privacy rights the Privacy Rule or HCHD privacy policies were violated If you are complaining about a HCHD privacy policy please use this space. Please Sign and Date this Complaint Signature Date Filing a complaint with the HCHD Office of Privacy Administration OPA is voluntary. However without the information requested above OPA 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 on this form is treated confidentially. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible violations regarding PHI for internal operations and for disclosures required by law. It is illegal for the Hospital District or any other covered entity to intimidate threaten coerce discriminate or retaliate against you for filing this complaint or taking any other action to enforce your rights under the Privacy Rule. Office of Privacy Administration 2525 Holly Hall P. O. Box 300033 Houston TX 77054 PRIVACY COMPLAINT FORM If you have any questions about this form call HCHD Office of Privacy Administration at 713-566-6097 Name Last First MI Telephone Home Telephone Work Street Address State City Zip Are you filing this claim for someone else E-Mail Address If Available Yes No If the complaint is regarding someone else please provide his/her Name Last First MI Who or what HCHD facility do you believe violated your or another s rights for privacy of Protected Health Information PHI or violated other parts of the Privacy Rule or HCHD privacy policies. Person Location/Facility When do you believe the violation occurred How and/or why do you believe your or another s privacy rights the Privacy Rule or HCHD privacy policies were violated If you are complaining about a HCHD privacy policy please use this space. .

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