Privacy Complaint Report
Reported by: Date:
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: OUCompliance@ouhsc.edu; 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.
Rev.1/2015 © 2015 Retain in Department Files