HIPAA (Privacy Rule) Complaint and Resolution Form
(Complete applicable Items)
Name of person bringing the issue to our attention _____________________________________
Address _______________________________________________________________________
City/State/Zip __________________________________________________________________
Phone __________________Fax ____________________e-mail _________________________
Physician(s) involved ____________________________________________________________
Medical Record # and Invoice # ____________________________________________________
Date and Place of Service: ________________________________________________________
Level of Service Coded: (CPT Code) ________________________________________________
Type of Service _________________________________________________________________
Name of employee completing this form _____________________________________________
Address _______________________________________________________________________
City/State/Zip __________________________________________________________________
Date issue first brought to our attention ______________________________________________
Employee Contacted _____________________________________________________________
By phone, in person, other ________________________________________________________
Was the person referred to someone else? Y N. If yes, Name of employee _________________
What did the person say: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What was the person told: _________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What was done to resolve this issue: ________________________________________________
______________________________________________________________________________
______________________________________________________________________________