Free Complaint Report - Wisconsin


File Size: 10.4 kB
Pages: 1
Date: August 25, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 225 Words, 1,504 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20009.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care Division of Mental Health and Substance Abuse Services F-20009 (07/2008)

STATE OF WISCONSIN WSS § 51.61 45 CFR § 164

COMPLAINT REPORT
This is a voluntary form. At the discretion of the Client Rights staff or HIPAA Privacy Officer, a complaint may be filed orally. This information is used only for investigation and resolution of this complaint. If you have any questions regarding this form or need assistance in the completion of it, contact the facility's Client Rights staff or Privacy Officer. Name - Patient / Client (Last, First MI) Name - Complainant (Last, First MI) (if not patient / client) Address Address

Telephone Number(s) Facility / Unit

Telephone Number(s)

This complaint alleges violation of: or

item
(Give Number, if known)

of the Patient Rights in Chapter 51 WSS.

the federal Health Insurance Portability and Accountability Act (HIPAA ­ 45 CFR § 164), regarding the use and disclosure of patient's protected health information. DESCRIBE YOUR COMPLAINT State all facts, including time, place of incident, names of other involved, witnesses, if any.

RELIEF SOUGHT (Not applicable for HIPAA Complaints)

I have also submitted this complaint to the following agency: If this issue relates to or involves a possible violation of HIPAA, the facility Privacy Officer must be notified SIGNATURE:
(Person Completing Report)

Date - Submitted:

Date - Received: DISTRIBUTION Original - Facility Client Rights Copy - Client