3.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services (Office for Civil Rights/U.S.
Department of Health & Human Services ______________________________) if you believe your
privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy
Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Officer, Dallas Lato at (_480___)___396 _-__2781_____
or
contactphysicaltherapy.comfor further information about the complaint process.
This notice was published and becomes effective on _______September 23 2013_______.
ACKNOWLEDGEMENT (to be signed by patient)
I, _______________________________________, hereby acknowledge that I have received and have
had the opportunity to review the Notice of Privacy Practices.
Date: ____________________________
Signature:
_______________________________________________
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