DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13152 (01/05)
STATE OF WISCONSIN P.L. 104-191
HIPAA PRIVACY COMPLAINT
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHFS, as a covered entity, to implement processes that give recipients certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of the information outlined on this form is mandatory. Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this purpose. INSTRUCTIONS: Mail this completed form to the following address: Wisconsin Medicaid Recipient Services PO Box 6678 Madison WI 53716-0678 SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial
Wisconsin Medicaid Identification Number
Address Street, City, State, ZIP Code
Telephone Number ( )
SECTION II COMPLAINT POLICY SUMMARY You have the right to file a complaint with the Wisconsin Division of Health Care Financing (DHCF) about our compliance with our Notice of Privacy Practices or our privacy policies and procedures. The DHCF will investigate your complaint and provide you with our written response. The DHCF will not require you to waive any rights you may have under federal or state privacy or other law to file your complaint, nor will filing your complaint affect the payment made by the DHCF for the health care provided to you. Further, you will not lose benefits or eligibility or otherwise be retaliated against for filing a complaint. To exercise this right, complete, sign, and date this form, then mail this complaint to the address listed above. If you have questions, need additional information or assistance in completing your complaint, contact Recipient Services at 1-800362-3002. You may in addition to, or instead of, filing a complaint with the DHCF, file a complaint with the United States Department of Health and Human Services. For information on the procedure for doing this, please contact the DHCF at the above location or call Recipient Services at 1-800-362-3002. SECTION III RECIPIENT'S COMPLAINT Give a concise statement of your complaint.
Wisconsin Medicaid HIPAA Privacy Complaint HCF 13152 (01/05)
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SECTION III RECIPIENT'S COMPLAINT (Continued) Give a concise statement of the resolution you seek for your complaint.
SECTION IV SIGNATURES Please sign the form and complete the appropriate information. SIGNATURE recipient Date Signed
If this request is from a personal representative on behalf of the recipient, provide a copy of the documentation to support the representation and complete the following: Name Personal Representative Relationship to recipient
SIGNATURE Personal Representative