HIPAA Privacy Complaint Form

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HIPAA Privacy Complaint Form Powered By Docstoc
					                                                St. John’s Health System
                                                       Corporate Privacy Officer

                                  HEALTH INFORMATION PRIVACY COMPLAINT
                           If you have questions about this form, call the SJHS Corporate Privacy Officer at:
                              1-888-664-4722 (Toll Free) or 417-820-8471 or (417) 820-6185 (Springfield, MO)
YOUR FIRST NAME                                         YOUR MIDDLE INITIAL            YOUR LAST NAME


HOME PHONE                    MOBILE PHONE                           WORK PHONE                               DATE OF BIRTH
(          )                  (         )                            (             )
STREET ADDRESS                                                                                      CITY


STATE                                 ZIP                                     E-MAIL ADDRESS (If available)



NOTE: A copy of your picture identification to include a current Driver’s License or Passport will need to be provided.

Are you filing this complaint for someone else?            Yes           No
                                  If Yes, whose health information privacy rights do you believe were violated?
FIRST NAME                                                                    LAST NAME



Who (or what provider or health plan) do you believe violated your (or someone else’s) health information privacy rights or
committed another violation of the Privacy Rule?
PERSON/AGENCY/ORGANIZATION



STREET ADDRESS                                                                                        CITY


STATE                                  ZIP                                     PHONE
                                                                               (        )
When do you believe that the violation of health information privacy rights occurred?
LIST DATE(S)


Describe briefly what happened. How and why do you believe your (or someone else’s) health information privacy rights were
violated, or the privacy rule otherwise was violated? Please be as specific as possible. (Attach additional pages as needed)




Signature and date required for processing.
SIGNATURE                                                                                           DATE



Filing a complaint with SJHS is voluntary. However, without the information requested above, SJHS may be unable to proceed with
your complaint. We will use the information you provide to determine how we will process your complaint. Information submitted on this
form is treated confidentially by SJHS 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 possible health information privacy violations or for
purposes associated with health information privacy compliance and as permitted by law. You are not required to use this form. You
also may write a letter. To mail a complaint see the reverse page for appropriate SJHS Privacy Site Coordinator addresses.

    Rev. 8/31/2009
If we cannot reach you directly, is there someone we can contact to help us reach you?
FIRST NAME                                                                         LAST NAME


HOME PHONE                                 MOBILE PHONE                            WORK PHONE
(           )                              (         )                             (           )
STREET ADDRESS                                                                                           CITY


STATE                                          ZIP                                 E-MAIL ADDRESS (If available)




                                To mail a complaint, please type or print, and return completed complaint to the
                     SJHS Privacy Site Coordinator Address based on the facility where the alleged discrimination took place.

                   St John’s Aurora                                     St John’s Berryville                              St John’s Cassville
    HIPAA Privacy Site Coordinator                       HIPAA Privacy Site Coordinator                    HIPAA Privacy Site Coordinator
    500 Porter Avenue                                    214 Carter Street                                 94 Main Street
    Aurora, MO 65605                                     Berryville, AR 72616                              Cassville, MO 65625
    (417) 678-7890                                       (870) 423-5228                                    (417) 847-6084
    (417) 678-7892 FAX                                   (870) 423-5281 FAX                                (417) 847-1454 FAX

                 St John’s Health System                               St John’s Home Care                                St John’s Lebanon
    Corporate Privacy Officer                            HIPAA Privacy Site Coordinator                    HIPAA Privacy Site Coordinator
    1235 E Cherokee St                                   1570 W. Battlefield                               100 Hospital Drive
    Springfield, MO 65804                                Suite 110                                         Lebanon, MO 65536
    (417) 820-8471; (888) 664-4722                       Springfield, MO 65807                             (417) 533-6010
    (417) 820-6696 FAX                                   (417) 820-5550                                    (417) 533-6173 FAX
                                                         (417) 820-5551 FAX
                  St John’s Mercy Villa                          St John’s Regional Health Center                   St John’s/St Francis Hospital
    HIPAA Privacy Site Coordinator                       HIPAA Privacy Site Coordinator                    HIPAA Privacy Site Coordinator
    1100 E Montclair                                     1235 E Cherokee St                                Highway 60, PO Box 82
    Springfield, MO 65802                                Springfield, MO 65804                             Mountain View, MO 65548
    (417) 820-8510                                       (417) 820-3095                                    (417) 934-7061
    (417) 820-8532 FAX                                   (417) 820-7811 FAX                                (417) 934-7066 FAX

            St John’s Clinic-Springfield Area                       St John’s Clinic-Rolla Area                        St John’s Health Plans
    HIPAA Privacy Site Coordinator                       HIPAA Privacy Site Coordinator                     HIPAA Privacy Site Coordinator
    Central Billing Office (CBO)                         1605 Martin Springs Drive                          3265 S. National Ave Suite 210
    620 S Glenstone Ave                                  Suite 360 B                                        Springfield, MO 65807
    Springfield, MO 65804                                Rolla, MO 65401                                    (417) 820-3826
    (417) 829-4326                                       (573) 458-6868                                     (417) 820-5401 FAX
    (417) 829-4500 FAX                                   (573) 458-6877 FAX

    HIPAA Privacy Site Coordinator
    Smith-Glynn-Calloway Clinic
    3231 South National Ave
    Springfield, MO 65807
    (417) 890-4131
    (417) 841-0150 FAX




    Rev. 8/31/2009