Form H0404, Privacy Complaint

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Documents

Effective Date: 2/2017

Instructions

Updated: 4/2017

Purpose

As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, you have the right to file a complaint. If you believe that the Texas Health and Human Services (HHS) violated your (or someone else's) health information privacy rights or committed another violation of the HIPAA or the Privacy Act 1976, you may file a complaint with the HHS Privacy Office. HHS has the independent authority to receive and investigate complaints against HHS staff and business associates.

Procedure

Number of Copies

The individual submits one completed Form H0404.

Transmittal

The complete Form H0404 may be returned by mail to:

Texas Health and Human Services
Privacy Office
P.O. Box 149030, Mail Code 135-5
Austin, TX 78714-9030

Email to: privacy@hhsc.state.tx.us

Form Retention

Form H0404 is kept by the Privacy Office for six years after the closure date (refer to HHSC Records Retention Schedule Agency Item Number 5576).

Detailed Instructions

First Name – Enter the first name.

Last Name – Enter the last name.

Street Address – Enter the street address.

City – Enter name of city.

State – Enter name of state.

ZIP Code – Enter ZIP code.

Home Telephone No. with Area Code – Enter home phone number.

Work Telephone No. with Area Code – Enter work phone number

Email Address – Enter email address.

Are you filing this complaint for someone else? – Enter yes or no.

If yes, whose privacy rights do you believe were violated? – Provide a brief description of whose privacy rights were violated.

First Name ­­ – Enter the first name of the person.

Last Name – Enter the last name of the person.

Date of Birth – Enter the date of birth of the person.

Relationship to the Person – Enter your relationship to the person.

When do you believe the violation of health information privacy rights occurred? – Provide the date the violation occurred.

Describe briefly how and why you believe a privacy violation occurred. – Provide a brief description.

Signature and Date – Sign and date the form.