Fillable OCR COMPLAINANT CONSENT FORM Health and Human Services

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OCR COMPLAINANT CONSENT FORM Health and Human Services

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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.
Please read and review the documents entitled, Protecting Personal Information in
Complaint Investigations and Notice to Complainants and Other Individuals Asked to
Supply Information to the Office for Civil Rights 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.
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• 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 type or print): ______________________________________________________
Address: ________________________________________________________________
Telephone Number: __________________________
Complainant Consent Form
Page 2 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.
Page 2 of 2
Notice to Complainants & Other Individuals Asked to Supply Information to OCR
Notice to Complainants and Other Individuals asked to Supply Information to the Office for Civil Rights
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".
PROTECTING PERSONAL INFORMATION I
COMPLAINT INVESTIGATIONS
N
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,
Page 1 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 fact sheet, please contact OCR
http://www.hhs.gov/ocr/contact.html
OR
Contact your OCR Regional Office
(see Regional Office contact information on page 2 of the Complaint Form)
Page 2 of 2
Protecting Personal Information in Complaint Investigations
Protecting Personal Information in Complaint Investigations
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OCR COMPLAINANT CONSENT FORM Health and Human Services

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Completed 1 December 2019

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