Thrive Counseling HIPAA Complaint Form
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you filing a complaint on behalf of another individual?
*
Yes
No
If yes, please provide the name of the individual:
Where did the violation occur?
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Birmingham Office
Hoover Office
Trussville Office
Other
Please provide the name(s) of the individual(s) you believe caused the violation. Note: The alleged violator(s) must be an employee of Thrive Counseling
*
When did the violation occur? If exact date(s) is unknown, provide approximate timeframe
*
When were you made aware of the violation?
*
What type of HIPAA violation occurred? Select all that are applicable:
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Unauthorized access/viewing of health information
Unauthorized disclosure of health information
Loss of health information records
Retaliation for filing a previous complaint
Failure to receive requested health records or accounting of disclosures
Other
In the space below, please summarize the HIPAA violation(s) you believe occurred
*
Signature
*
Submit
Should be Empty: