Privacy Complaint

Privacy Complaint

Use this form to file a Privacy Violation Complaint with the Central DuPage Pastoral Counseling Center
Name*

First NameLast Name
Your Initials*
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Daytime Phone Number*
Please enter a valid phone number.
HomeOfficeCell
Are you filing this complaint for someone else?*

YesNo
If yes, whose health information privacy rights do you believe were violated?

First NameLast Name
Name of the person and/or facility you believe violated your (or someone else’s) health information privacy rights or committed another violation of the HIPAA Privacy Rule?*
When do you believe that the violation of health information privacy rights occurred?date
Briefly describe what happened. How and why do you believe your health information privacy rights were violated (or someone else’s), or the HIPAA Privacy Rule was violated? Please be as specific as possible.
Your Signature

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Today's Date

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Your complaint will be taken very seriously. Our Chief Privacy Officer and our Hipaa Compliance Officer will review and investigate your concerns and then contact you to help find a satisfactory remedy to your complaint. If none can be found, we will file a formal report with the appropriate governing body. In the meantime, feel free to contact our Director of Counseling Services, Dr. Patricia Francis, O.P. (630-791-4917) if you have any questions about this process.
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