Fillable Form hhs-758 PATIENT SAFETY CONFIDENTIALITY COMPLAINT

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Form hhs-758 PATIENT SAFETY CONFIDENTIALITY COMPLAINT

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The Form hhs-758 PATIENT SAFETY CONFIDENTIALITY COMPLAINT form is 2 pages long and contains:

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  • 19 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office for Civil Rights (OCR)
PATIENT SAFETY CONFIDENTIALITY COMPLAINT
Home Phone (Please include area code)
State
Phone
ZIP
When do you believe that the impermissible disclosure occurred?
Describe briefly what happened. How and why do you believe a person or organization impermissibly disclosed patient safety
work product? Please be as specific as possible. Why do you believe the information disclosed is patient safety work product?
(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.
Date (mm/dd/yyyy)
Signature
HHS-758 (11/08) PAGE 1 OF 2
PSC Graphics (301) 443-1090 EF
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 the Patient Safety and Quality Improvement Act of 2005 (Patient Safety
Act). We use it to investigate your complaint to see whether enforcement action is appropriate. The Privacy Act of 1974
protects the information submitted on this form. We may share your information with the Department of Justice or a court in
the event of a lawsuit, with another agency that has jurisdiction over potential violations or reviews certifications of Patient
Safety Organizations, or with others who help us carry out our work. Otherwise, OCR will not share your name or other
identifying information about you unless you agree. You are not required to use this form. You may write a letter or submit a
complaint electronically with the same information. You will find directions for submitting an electronic complaint on our web
site at http://hhs.gov/ocr/privacy/psa/complaint/index.html. To mail a complaint see reverse page for OCR address.
State
List Date(s)
Who is the patient, provider or reporter who is identified in the information you believe was impermissibly disclosed?
City
ZIP
E-Mail Address (If available)
Street Address
City
Street Address
Your First Name Your Last Name
First Name or Business Name
Last Name (Leave blank if using Business Name to left)
Person/Agency/Organization
Who (e.g., provider, patient safety organization, other person) do you believe disclosed patient safety work product in violation
of patient safety confidentiality?
Work Phone (Please include area code)
Form Approved: OMB No. 0935-0143 See OMB Statement on page 2.
PAGE 2 OF 2HHS-758 (11/08)
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 us to communicate with you about this complaint? (Check all that apply)
Sign language interpreter (Specify language):
Braille Large print TDDElectronic MailComputer diskette
HHS Website / Internet Search
Phone Directory
Religious / Community Org Lawyer / Legal Org
Fed / State / Local Gov Healthcare Provider / Health Plan
Family / Friend / Associate
Employer
Other (Specify):
Conference / OCR Brochure
Cassette tape
Other (Specify):
Foreign language interpreter (Specify language):
HOW DID YOU LEARN ABOUT THE OFFICE FOR CIVIL RIGHTS?
To help us better serve you, answer the following question.
Last Name
If we cannot reach you directly, is there someone we can contact to help us reach you?
First Name
CityStreet Address
Office for Civil Rights
Department of Health and Human Services
Attn: Patient Safety Act
200 Independence Ave., SW, Rm. 509F
Washington, DC 20201
(202) 619-0403
TDD 1-800-537-7697
FAX: (202) 619-3818
Work Phone (Please include area code)Home Phone (Please include area code)
E-Mail Address (If available)
ZIPState
Case Number(s) (If known)
Date(s) Filed
Person / Agency / Organization / Court Name(s)
To submit an electronic complaint, see our web site at http://hhs.gov/ocr/privacy/psa/complaint/index.html.
Have you filed your complaint anywhere else? If so, please provide the following: (Attach additional pages as needed)
To mail a complaint, please type or print, and return completed complaint to:
Burden Statement
Public reporting burden for the collection of information on this complaint form is estimated to average 20 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 information,
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.
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Form hhs-758 PATIENT SAFETY CONFIDENTIALITY COMPLAINT

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Completed 2 December 2019

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