HIPAA Complaint Form 6.5.1 by ChristMoore

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									                                 HIPAA COMPLAINT FORM


Patient Name:                                  Saint Louis County DOH Facility:

                                               Medical Record Number:

Patient Address & Phone Number:




Today’s Date:          Date(s) acts or omissions are to have occurred:



Description of acts or omission believed to be in violation:




Please describe the Protected Health Information (PHI) affected:




Do you know of anyone who may have received the PHI?           Yes     No
If so, please specify the name and address of the organization or individual:




                _______________________________________                  __________
                   Signature of Patient or Legal Representative              Date


                     Section Below for Saint Louis County DOH Use Only

                         Violation Occurred          No Violation Occurred

CL/cag/lms
041403

6.5.1 HIPAA Complaint Form                                                      Page 1 of 1

								
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