Washington Health Information Privacy Complaint Form for filing with HIPAA Privacy Office
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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.
You may submit your complaint to the CDPH Privacy Office or to the U.S. Department of Health and Human Services (DHHS) (for complaints of violation of HIPAA only), or to both agencies at the addresses provided below.
If you believe the Department may have violated your privacy, please complete the Privacy Complaint Form. You also may write or submit a complaint electronically with the same information. To submit a privacy complaint electronically please email the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa.gov.
If a complaint describes an action that could be a violation of the criminal provision of HIPAA (42 U.S.C. 1320d-6), OCR may refer the complaint to the Department of Justice for investigation. OCR reviews the information, or evidence, that it gathers in each case.
The Office of Civil Rights (OCR) is a federal agency that investigates complaints of discrimination on the basis of race, color, national origin, sex, disability and age in public schools.
If you believe that a covered entity discriminated against you or violated your (or someone else's) civil rights, conscience rights, or religious freedom rights, you may file a complaint with OCR. You may file a complaint for yourself, your organization, or for someone else.
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.
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?
