Fillable Form hhs-700 HEALTH INFORMATION PRIVACY & SECURITY COMPLAINT

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Form hhs-700 HEALTH INFORMATION PRIVACY & SECURITY COMPLAINT

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The Form hhs-700 HEALTH INFORMATION PRIVACY & SECURITY COMPLAINT form is 4 pages long and contains:

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  • 14 check-boxes
  • 63 other fields

Country of origin: US
File type: PDF

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Form Approved: OMB No. 0945-0002.
Expiration Date: 10/31/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE FOR CIVIL RIGHTS (OCR)
HEALTH INFORMATION PRIVACY & SECURITY COMPLAINT
YOUR FIRST NAME
YOUR LAST NAME
HOME PHONE (Please include area code)
( )
WORK PHONE (Please include area code)
( )
STREET ADDRESS
CITY
STATE
ZIP
E-MAIL ADDRESS (If available)
Are you filing this complaint for someone else? Yes No
If Yes, whose health information privacy rights do you believe were violated?
LAST NAME
Who (or what agency or organization, e.g., provider, health plan) do you believe violated your (or someone else’s) health
information privacy rights or committed another violation of the Privacy Rule or Security Rules?
PERSON / AGENCY / ORGANIZATION
STREET ADDRESS
CITY
STATE
ZIP
PHONE (Please include area code)
( )
When do you believe that the violation of health information privacy rights occurred?
LIST DATE(S)
Describe briefly what happened. How and why do you believe your (or someone else’s) health information privacy rights
were violated, or how another violation of the Privacy or Security Rules occurred? Please be as specific as possible.
(Attach additional pages as needed)
Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.
SIGNATURE
DATE (mm/dd/yyy)
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your
complaint. We collect this information under authority 45 CFR 160 & 164 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 submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of
1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible health
information privacy violations, for internal systems operations, or for routine uses, which include disclosure of information outside the
Department for purposes associated with health information privacy compliance and as permitted by law. It is illegal for a covered
entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to
enforce your rights under the Privacy Rule. You are not required to use this form. You also may write a letter or submit a complaint
electronically with the same information. To submit an electronic complaint, go to OCR’s Web site at:
www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. To mail a complaint see page 2 of this form for the mailing address.
HHS-700 (11/15)(FRONT)
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signature
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The remaining information on this form is optional. Failure to answer these voluntary
questions will not affect OCR's decision to process your complaint.
Do you need special accommodations for OCR to communicate with you about this complaint? (check all that apply)
Braille Large Print Cassette tape Computer diskette Electronic mail TDD
Sign language interpreter (specify language):
Foreign language interpreter (specify language):
If we cannot reach you directly, is there someone we can contact to help us reach you?
FIRST NAME
LAST NAME
HOME PHONE (Please include area code)
( )
WORK PHONE (Please include area code)
( )
STREET ADDRESS
CITY
STATE
ZIP
E-MAIL ADDRESS (If available)
Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed)
PERSON / AGENCY / ORGANIZATION / COURT NAME(S)
DATE(S) FILED
CASE NUMBER(S) (If known)
To help us better serve the public, please provide the following information for the person you believe had their health
information privacy rights violated (you or the person on whose behalf you are filing).
ETHNICITY (select one) RACE (select one or more)
Hispanic or Latino American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander
Not Hispanic or Latino Black or African American White Other (specify):
PRIMARY LANGUAGE SPOKEN (if other then English)
How did you learn about the Office for Civil Rights?
HHS Website/Internet Search Family/Friend/Associate Religious/Community Org Lawyer/Legal Org Phone Directory Employer
Fed/State/Local Gov Healthcare Provider/Health Plan Conference/OCR Brochure Other (specify):
To submit a complaint, please type or print, sign, and return completed complaint form package (including consent form) to the
OCR Headquarters address below.
U.S. Department of Health and Human Services
Office for Civil Rights
Centralized Case Management Operations 200 Independence Ave., S.W.
Suite 515F, HHH Building
Washington, D.C. 20201
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
Email: ocrmail@hhs.gov
Burden Statement
Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for reviewing instructions,
gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of i
nformation,
including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H,
Washington, D.C. 20201. Please do not mail this complaint form to this address.
HHS-700 (11/15) (BACK)
Other:
Complaint Consent Form Page 1 of 2
COMPLAINANT CONSENT FORM
The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR)
has the authority to collect and receive material and information about you, including
personnel and medical records, which are relevant to its investigation of your complaint.
To investigate your complaint, OCR may need to reveal your identity or identifying
information about you to persons at the entity or agency under investigation or to other
persons, agencies, or entities.
The Privacy Act of 1974 protects certain federal records that contain personally
identifiable information about you and, with your consent, allows OCR to use your name
or other personal information, if necessary, to investigate your complaint.
Consent is voluntary, and it is not always needed in order to investigate your complaint;
however, failure to give consent is likely to impede the investigation of your complaint
and may result in the closure of your case.
Additionally, OCR may disclose information, including medical records and other
personal information, which it has gathered during the course of its investigation in
order to comply with a request under the Freedom of Information Act (FOIA) and may
refer your complaint to another appropriate agency.
Under FOIA, OCR may be required to release information regarding the investigation of
your complaint; however, we will make every effort, as permitted by law, to protect
information that identifies individuals or that, if released, could constitute a clearly
unwarranted invasion of personal privacy.
P
lease read and review the documents entitled, Notice to Complainants and Other
Individuals Asked to Supply Information to the Office for Civil Rights and Protecting
Personal Information in Complaint Investigations for further information regarding how
OCR may obtain, use, and disclose your information while investigating your
complaint.
In order to expedite the investigation of your complaint if it is accepted by OCR,
please read, sign, and return one copy of this consent form to OCR with your
complaint. Please make one copy for your records.
• As a complainant, I understand that in the course of the investigation of my
complaint it may become necessary for OCR to reveal my identity or identifying
information about me to persons at the entity or agency under investigation or to
other persons, agencies, or entities.
Complaint Consent Form Page 2 of 2
• I am also aware of the obligations of OCR to honor requests under the Freedom
of Information Act (FOIA). I understand that it may be necessary for OCR to
disclose information, including personally identifying information, which it has
gathered as part of its investigation of my complaint.
• In addition, I understand that as a complainant I am covered by the Department
of Health and Human Services’ (HHS) regulations which protect any individual
from being intimidated, threatened, coerced, retaliated against, or discriminated
against because he/she has made a complaint, testified, assisted, or participated
in any manner in any mediation, investigation, hearing, proceeding, or other part
of HHS’ investigation, conciliation, or enforcement process.
After reading the above information, please check ONLY ONE of the following boxes:
CONSENT: I have read, understand, and agree to the above and give
permission to OCR to reveal my identity or identifying information about me in my case
file to persons at the entity or agency under investigation or to other relevant persons,
agencies, or entities during any part of HHS’ investigation, conciliation, or enforcement
process.
CONSENT DENIED : I have read and I understand the above and do not give
permission to OCR to reveal my identity or identifying information about me. I
understand that this denial of consent is likely to impede the investigation of my
complaint and may result in closure of the investigation.
Signature: Date:
*Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.
Name (Please print):
Address:
Telephone Number:
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signature
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Notice to Complainants and Other Individuals Page 1 of 2
NOTICE TO COMPLAINANTS AND OTHER
INDIVIDUALS ASKED TO SUPPLY INFORMATION
TO THE OFFICE FOR CIVIL RIGHTS
Privacy Act
The Privacy Act of 1974 (5 U.S.C. §552a) requires OCR to notify individuals whom it asks to
supply information that:
— OCR is authorized to solicit information under:
(i) Federal laws barring discrimination by recipients of Federal financial assistance on grounds
of race, color, national origin, disability, age, sex, religion under programs and activities
receiving Federal financial assistance from the U.S. Department of Health and Human Services
(HHS), including, but not limited to, Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d
et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794), the Age Discrimination
Act of 1975 (42 U.S.C. §6101 et seq.), Title IX of the Education Amendments of 1972 (20
U.S.C. §1681 et seq.), and Sections 794 and 855 of the Public Health Service Act (42 U.S.C.
§§295m and 296g);
(ii) Titles VI and XVI of the Public Health Service Act (42 U.S.C. §§291 et seq. and 300s et
seq.) and 42 C.F.R. Part 124, Subpart G (Community Service obligations of Hill- Burton
facilities);
(iii) 45 C.F.R. Part 85, as it implements Section 504 of the Rehabilitation Act in programs
conducted by HHS; and
(iv) Title II of the Americans with Disabilities Act (42 U.S.C. §12131 et seq.) and Department
of Justice regulations at 28 C.F.R. Part 35, which give HHS "designated agency" authority to
investigate and resolve disability discrimination complaints against certain public entities,
defined as health and service agencies of state and local governments, regardless of whether they
receive federal financial assistance.
(v) The Standards for the Privacy of Individually Identifiable Health Information (The Privacy
Rule) at 45 C.F.R. Part 160 and Subparts A and E of Part 164, which enforce the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. §1320d-2).
OCR will request information for the purpose of determining and securing compliance with the
Federal laws listed above. Disclosure of this requested information to OCR by individuals who
are not recipients of federal financial assistance is voluntary; however, even individuals who
voluntarily disclose information are subject to prosecution and penalties under 18 U.S.C. § 1001
for making false statements.
Additionally, although disclosure is voluntary for individuals who are not recipients of federal
financial assistance, failure to provide OCR with requested information may preclude OCR from
making a compliance determination or enforcing the laws above.
Notice to Complainants and Other Individuals Page 2 of 2
OCR has the authority to disclose personal information collected during an investigation without
the individual’s consent for the following routine uses:
(i) to make disclosures to OCR contractors who are required to maintain Privacy Act
safeguards with respect to such records;
(ii) for disclosure to a congressional office from the record of an individual in response to an
inquiry made at the request of the individual;
(iii) to make disclosures to the Department of Justice to permit effective defense of litigation;
and
(iv) to make disclosures to the appropriate agency in the event that records maintained by OCR
to carry out its functions indicate a violation or potential violation of law.
Under 5 U.S.C. §552a(k)(2) and the HHS Privacy Act regulations at 45 C.F.R. §5b.11 OCR
complaint records have been exempted as investigatory material compiled for law enforcement
purposes from certain Privacy Act access, amendment, correction and notification requirements.
Freedom of Information Act
A complainant, the recipient or any member of the public may request release of OCR records
under the Freedom of Information Act (5 U.S.C. §552) (FOIA) and HHS regulations at 45
C.F.R. Part 5.
Fraud and False Statements
Federal law, at 18 U.S.C. §1001, authorizes prosecution and penalties of fine or imprisonment
for conviction of "whoever, in any matter within the jurisdiction of any department or agency of
the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme,
or device a material fact, or makes any false, fictitious or fraudulent statements or
representations or makes or uses any false writing or document knowing the same to contain any
false, fictitious, or fraudulent statement or entry".
Notice to Complainants and Other Individuals Page 1 of 2
PROTECTING PERSONAL INFORMATION IN
COMPLAINT INVESTIGATIONS
To investigate your complaint, the Department of Health and Human Services’ (HHS)
Office for Civil Rights (OCR) will collect information from different sources. Depending
on the type of complaint, we may need to get copies of your medical records, or other
information that is personal to you. This Fact Sheet explains how OCR protects your
personal information that is part of your case file.
HOW DOES OCR PROTECT MY PERSONAL INFORMATION?
OCR is required by law to protect your personal information. The Privacy Act of 1974
protects Federal records about an individual containing personally identifiable
information, including, but not limited to, the individual’s medical history, education,
financial transactions, and criminal or employment history that contains an individual’s
name or other identifying information.
Because of the Privacy Act, OCR will use your name or other personal information with a
signed consent and only when it is necessary to complete the investigation of your
complaint or to enforce civil rights laws or when it is otherwise permitted by law.
Consent is voluntary, and it is not always needed in order to investigate your complaint;
however, failure to give consent is likely to impede the investigation of your complaint
and may result in the closure of your case.
CAN I SEE MY OCR FILE?
Under the Freedom of Information Act (FOIA), you can request a copy of your case file
once your case has been closed; however, OCR can withhold information from you in
order to protect the identities of witnesses and other sources of information.
CAN OCR GIVE MY FILE TO ANY ONE ELSE?
If a complaint indicates a violation or a potential violation of law, OCR can refer the
complaint to another appropriate agency without your permission.
If you file a complaint with OCR, and we decide we cannot help you, we may refer your
complaint to another agency such as the Department of Justice.
CAN ANYONE ELSE SEE THE INFORMATION IN MY FILE?
Access to OCR’s files and records is controlled by the Freedom of Information Act
(FOIA). Under FOIA, OCR may be required to release information about this case upon
public request. In the event that OCR receives such a request, we will make every effort,
Notice to Complainants and Other Individuals Page 2 of 2
as permitted by law, to protect information that identifies individuals, or that, if released,
could constitute a clearly unwarranted invasion of personal privacy.
If OCR receives protected health information about you in connection with a HIPAA
Privacy Rule investigation or compliance review, we will only share this information with
individuals outside of HHS if necessary for our compliance efforts or if we are required to
do so by another law.
DOES IT COST ANYTHING FOR ME (OR SOMEONE ELSE) TO OBTAIN A
COPY OF MY FILE?
In most cases, the first two hours spent searching for document(s) you request under the
Freedom of Information Act and the first 100 pages are free. Additional search time or
copying time may result in a cost for which you will be responsible. If you wish to limit
the search time and number of pages to a maximum of two hours and 100 pages; please
specify this in your request. You may also set a specific cost limit, for example, cost not to
exceed $100.00.
If you have any questions about this complaint and consent package,
Please contact OCR at http://www.hhs.gov/ocr/office/about/contactus/index.html
OR
Contact the Customer Response Center at (800) 368-1019
(see contact information on page 2 of the Complaint Form)
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Form hhs-700 HEALTH INFORMATION PRIVACY & SECURITY COMPLAINT

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