Privacy Complaint Form

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					                                                        PRIVACY COMPLAINT FORM

This form is for the use of submitting a privacy concern or complaint about the privacy policies or practices of TRICARE, a provider of service
or Health Net Federal Services, Inc. (HNFS).

You have the right to file a privacy complaint with HNFS (your TRICARE North contractor), the TRICARE Management Activity (TMA) Privacy
Official, the Military Treatment Facility (MTF) Privacy Official, or with the Secretary of the Department of Health and Human Services (DHHS).

Filing a complaint is voluntary. However, without the information requested, HNFS may be unable to proceed with the investigation of your
complaint. 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 information outside the Military Health System
(MHS)/TRICARE 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 HHS Privacy Rule. You are entitled to a copy of this complaint.
Section A: Individual Submitting Concern or Complaint



Telephone: Home         (     )                                              Work       (     )


Sponsor Social Security Number:                                                    Beneficiary SSN:
Section B: Description of Privacy Concern or Complaint

Please select one:                    Concern                                   Complaint
Please provide a statement of what happened. How and why do you believe your (or someone else’s) health information privacy
rights were violated? What person or facility do you believe violated your (or someone else’s) health information privacy rights?
When did the incident occur? Please be as specific as possible (attach additional pages if needed and provide documentation if

What resolution do you seek from submitting your concern or complaint?

I certify that the statements made in this concern or complaint are true and correct to the best of my knowledge.

Beneficiary Signature*                                                      Date
* If submitted by a personal representative on behalf of the beneficiary, complete the following:

Personal Representative’s Name

Relationship to Beneficiary

You will be contacted in writing and notified of the results of the investigation of your concern or complaint.

Please submit the completed and signed form to: Health Net Federal Services, Inc., Privacy Compliance Office, 2025 Aerojet Road, Rancho Cordova,
CA 95742 or fax to (916) 351-5120.

DEC05.047 (3/06 H90)                                                                                   HNFS Privacy Compliance 03/03/2006

Description: This is an example of privacy complaint form. This document is useful for studying privacy complaint form.