Oberlin College

HIPAA Privacy Complaint Form

 

As required by the Health Insurance Portability and Accountability Act (HIPAA) you have the right to complain about the privacy policies, procedures, or actions of Oberlin College.  In general, upon receipt of a complaint, the Privacy Officer for Oberlin College will, within 30 days of receiving the complaint, attempt to come to an appropriate resolution. Oberlin College will not engage in any discriminatory or other retaliatory behavior against you because of this complaint. Please be as thorough as possible in your written details.

 

Please complete the sections below:

 

Name: __________________________________________________________

 

Address: _________________________________________________________

 

Phone: _______________________ Email Address: ______________________

 

What is the best way and time to contact you? ___________________________

 

Please describe in detail the nature of your privacy complaint, including the date(s) and time(s) of the violation(s), the name(s) of any Oberlin College personnel involved, and any witnesses. Attach additional sheet(s) if necessary.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Signature: _________________________________ Date: _________________

 

This section is to be completed by the Oberlin College Privacy Officer

 

Date Received: _______________ Reviewed by: _________________________

 

Privacy Officer’s Comments: _________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Please print, complete, and return form to:

Privacy Office, c/o Kim Wiggerly, Oberlin College, Service bldg, 2nd Floor, 173 West Lorain Street, Oberlin, OH 44074, fax 440-775-8683

 

03/06