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2. This form may be used to report HIPAA privacy incidents. Filing a complaint is voluntary. However, without the information requested below, we may be unable to fully investiage your complaint.

   Please complete all applicable fields. You will receive a response from staff within two business days.

   You may also call Kayla Wharton at 301-600-1308 to report a HIPAA incident.

4. Date of Complaint*
   Date of Complaint
5. Date of Breach*
   Date of Breach
7. First Name*
8. Last Name*
9. Contact Number*
11. Address*
13. City*
14. State*
15. Zip*
17. Are you filing a complaint for someone else?*

    1. Yes
    2. No
19. If yes, whose privacy rights do you think were violated?
20. First Name
21. Last Name
23. Department the complaint pertains to:*
25. Types of unsecured Personal Health Information involved in the breach.

    Please check all that apply.

    1. Full Name
    2. Social Security Number
    3. Date of Birth
    4. Home Address
    5. Diagnosis
    6. Computer IP Address
    7. Credit card number or other financial info

    1. Date of Service
    2. Device Identification or Serial Number
    3. Driver's License Number
    4. Email address
    5. Fax Number
    6. Location of Service

    1. Medications
    2. Medical Record Number
    3. Photo
    4. Provider Name
    5. Lab Results
    6. Other
27. Please describe how, why, and when do you believe your (or someone else's) health information privacy rights were violated, or how the Privacy or Security Rule otherwise was violated. Be descriptive and give as much detail as possible.*
29. By typing in my first and last name below, I certify that the statements made in this complaint are true and correct.*
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field