Get the free OP1-13.5b HIPAA Complaint Form- University.doc - semo

HEALTH INFORMATION PRIVACY COMPLAINT FORM SOUTHEAST MISSOURI STATE UNIVERSITY Dr. Fred Janos, Vice Provost and HIPAA Complaint Officer One University Plaza, Mail stop 3400, Cape Mirabeau, Missouri

How to fill out op1-135b hipaa complaint form

How to fill out op1-135b hipaa complaint form:

Start by providing your personal information:

1. Enter your full name, address, and contact details in the designated fields.
2. Include any alternative or representative information, if applicable, such as a guardian or power of attorney.

Specify the covered entity or business associate:

1. Indicate the name, address, and contact information of the organization involved in the alleged HIPAA violation.
2. If you are unsure of the exact details, try to provide as much information as possible to help identify the entity.

Explain the nature of the complaint:

1. Describe the incident or violation that prompted the need for filing the complaint in detail.
2. Provide any relevant dates, locations, and individuals involved, if known.
3. Be clear and concise when outlining the specific HIPAA rules or regulations that were violated.

State the desired resolution or outcome:

1. Clearly express what you hope to achieve by filing the complaint.
2. This could include seeking corrective actions, imposing penalties, or raising awareness of the issue.
3. If you have any supporting documents or evidence, mention their existence and provide copies if required.

Sign and date the form:

1. Once you have completed all the necessary sections, sign and date the complaint form.
2. Ensure your signature matches the name provided at the beginning of the form.

Who needs op1-135b hipaa complaint form:

The op1-135b HIPAA complaint form is intended for individuals or entities who wish to report a violation of HIPAA regulations. This can include patients, healthcare professionals, employees, caregivers, or anyone who believes their privacy rights or the security of their health information has been compromised. By filling out this form, individuals take an active role in notifying the appropriate authorities and seeking resolution for the violation they have encountered.

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