To submit the HIPAA Non-Privacy Complaint Form, gather your completed form along with any additional documents that support your case. You can mail the completed form to the Centers for Medicare & Medicaid Services at P.O. Box 8030, Baltimore, Maryland 21244-8030. For further assistance, you may contact OHS at 1(866) 282-0659 or fax your documents to the appropriate department.

Important dates for the HIPAA Non-Privacy Complaint Form include deadlines for submitting complaints and updates on regulatory changes. It is essential to stay informed about any modifications to HIPAA compliance dates in 2024 and 2025. Consult the CMS website for the most accurate and current information.

The purpose of the HIPAA Non-Privacy Complaint Form is to provide a standardized method for individuals and organizations to report complaints related to HIPAA non-privacy violations. Utilizing this form ensures that complaints are documented and processed efficiently by the appropriate authorities. By filing this complaint, you help promote accountability and compliance within the healthcare sector.

• 1. Your Name: Input the first and last name of the complainant.
• 2. Organization Name: Specify the name of your organization if applicable.
• 3. Street Address: Enter the complete street address for contact purposes.
• 4. Telephone Number: Provide a reliable telephone number.
• 5. City/Town: Input the city or town of residence.
• 6. County: Indicate the county for your address.
• 7. State: Provide the state of residence.
• 8. ZIP: Enter the ZIP code.
• 9. Complaint Against: Specify the organization against which the complaint is filed.
• 10. Contact Name: Provide contact person's name at the organization.
• 11. Violation Date: Input the date when the alleged violation occurred.
• 12. Complaint Category: Select the relevant category for the complaint.
• 13. Allegation Details: Describe the violation in detail.
• 14. Signature: Place the signature of the complainant.
• 15. Date: Indicate the date of signature.

Failure to submit this form may result in your complaint not being acknowledged or processed by the appropriate authorities. It is crucial to provide complete and accurate information to avoid delays in handling your complaint. Incomplete submissions may hinder the investigation into the alleged violation.

• Lack of Acknowledgment: Your complaint may remain unaddressed, leading to no action being taken.
• Delayed Investigations: Missing information might prolong the investigation process.
• Potential Violations Continue: Without submission, violations may persist without oversight.

• 1. Health Information Mishandling: If your health information was shared without consent, file a complaint.
• 2. Compliance Failures: Use the form to report healthcare providers not compliant with HIPAA regulations.
• 3. Unresolved Disputes: When informal resolutions fail, this form allows for a formal approach.