Cameron University
Health Plan
Privacy Complaint Report
Reported by: Date:
Contact Information:
Email Address: Telephone Number:
Statement of Complaint:
Date of Occurrence:
Location of Occurrence:
Individuals filing a complaint may submit this form to the Employee Health Plan or to the University Privacy Official by
email:; fax: (405) 271-5545; or mail to: University of Oklahoma Privacy Official, P O Box 26901, Oklahoma
City, OK 73190.
Individuals may also contact the Secretary of Health and Human Services Office of Civil Rights DHHS, 1301 Young Street, Suite 1169,
Dallas TX, 75202, (214) 767-4066; (214) 767-8940 TDD.
HIPAA Document
Rev.1/2015 © 2015 Retain in Department Files