Nebraska Health Information Privacy Complaint Form for filing with HIPAA Privacy Office

State:
Multi-State
Control #:
US-354EM
Format:
Word; 
Rich Text
Instant download

Description

This form is used to initiate a complaint based on a violation of the HIPPA laws.

How to fill out Health Information Privacy Complaint Form For Filing With HIPAA Privacy Office?

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FAQ

Your complaint must: Be filed in writing by mail, fax, e-mail, or via the OCR Complaint Portal. Name the covered entity or business associate involved, and describe the acts or omissions, you believed violated the requirements of the Privacy, Security, or Breach Notification Rules.

Healthcare providers (including doctors, nurses, hospitals, dentists, nursing homes, and pharmacies). As a healthcare worker, you are part of the "healthcare provider" network and therefore are required to comply with HIPAA rules and regulations regarding Protected Health Information (PHI).

What is the key to success for HIPAA compliance? A HIPAA compliance plan should include: HIPAA policies to protect patient health information. Risk Analysis and Risk Management policies, with Risk Analysis conducted every year and Risk Management all year round.

To submit an electronic complaint, go to OCR's Web site at: .hhs.gov/ocr/privacy/hipaa/complaints/index.html. To submit a complaint using alternative methods, see reverse page (page 2 of the complaint form). When do you believe that the violation of health information privacy rights occurred?

The Privacy Office can be reached at 402-559-5136 or at privacy@nebraskamed.com. Individuals who desire to remain anonymous may report the suspected Privacy Incident through the Compliance Hotline at 800-822-8310. The Medical Staff may report suspected Privacy Incidents to the System Chief Medical Officer (CMO).

Establish and maintain procedures for handling security breaches and unauthorized access attempts. Regularly review and monitor access logs for any potential unauthorized access. Implement comprehensive user logging and auditing procedures. Develop and implement backup procedures that comply with HIPAA guidelines.

To achieve HIPAA compliance, organizations must address the following requirements: Administrative Safeguards: The development of written policies and procedures related to PHI security and privacy, designation of a privacy and security officer, workforce training on HIPAA regulations, and risk analysis and management.

Your complaint must: Be filed in writing: sent by mail, fax or e-mail. Name the person that is the subject of the complaint and describe the act or acts believed to be in violation of the Patient Safety Act requirement to keep PSWP confidential.

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Nebraska Health Information Privacy Complaint Form for filing with HIPAA Privacy Office