Free HIPAA Complaint Form Template

HIPAA Complaint Form

Please complete all sections to ensure proper review and resolution.

Date of Incident

    Name

      Phone Number

        Type of Complaint

        Check all that apply:

          • Unauthorized Use of Access to PHI

          • Improper Disclosure of PHI

          • Failure to Provide Access to Records

          • Violation of Privacy Rights

          Description of Complaint

            Desired Outcome

            Please describe the resolution or outcome you are seeking:

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