Pennsylvania 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

If you believe a privacy violation has taken place, you should report it to the Privacy Officer responsible for HIPAA compliance at the organization where the violation occurred. If you fail to get an appropriate response, you can escalate the report to your state Attorney General or HHS´ Office for Civil Rights.

Failure to comply with HIPAA can also result in civil and criminal penalties. If a complaint describes an action that could be a violation of the criminal provision of HIPAA, OCR may refer the complaint to the Department of Justice (DOJ) for investigation.

If you suspect a violation of your HIPAA privacy rights, you can report it anonymously. You may do so by calling 1-866-633-6472, or filling out this complaint form.

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?

If you believe a privacy violation has taken place, you should report it to the Privacy Officer responsible for HIPAA compliance at the organization where the violation occurred. If you fail to get an appropriate response, you can escalate the report to your state Attorney General or HHS´ Office for Civil Rights.

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.

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.

HIPAA Breach Notification Rule. Not all HIPAA violations are required to be reported to the relevant patient or HHS. Under the breach notification rule, covered entities are only required to self-report if there is a ?breach? of ?unsecured? PHI. (45 CFR § 164.400 et seq.).

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