Privacy Office 1-866-329-7592
PO Box 38115
Pittsburgh, PA 15238
Privacy Complaint Form
As required by the Health Insurance Portability and Accountability Act of 1996 you have a right
to complain about PharmaCare Directs privacy policies, procedures or actions. Please fill out
this form completely and accurately. Within 30 days of receipt of this Complaint Form, the
Privacy Office will review and respond to your Complaint. If you need assistance completing
this form, please call 1-866-329-7592 and a Privacy Office Representative will assist you.
Please note the Pharmacy cannot accept this form. It is your responsibility to mail this
form to the Privacy Office at the address listed above.
Please complete the sections below. (You are not required to provide your name and contact
information, but we will be unable to respond to your complaint if you choose not to provide this
information on this Complaint Form.)
Best way to reach you?
Best time to reach you?
This complaint relates to:
____ PharmaCare Direct Pittsburgh Mail Service Facility
____ PharmaCare Direct Clearwater (Largo) Mail Service Facility
____ Other (explain) __________________________________________________________
Details of your complaint: (Please be as specific as possible with dates, times and the specific
policy, procedure, or action taken. Include the names of any mail service associate(s) with
whom you discussed this matter, and identify pharmacy location. Use the other side of this form
or attach a separate page if you need more room.)
Created on 03/11/2005 11:07 AM