HIPAA Privacy Complaint Form

Do we have permission to leave a message at the phone number listed?

Name of University Unit (if known)

Name(s) of any known Unit Contact Persons:

Name of individual whose privacy rights may have been compromised (if applicable)

Are you filing this complaint for someone else?


Nature of perceived violation:

Date of Incident (if known)

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.