Please include a specific date. If that date is not available, enter an approximate date.
Please provide a detailed description of your complaint covering what when who how where and if you know why regarding what happened.
If you answered "yes" to the previous question, please provide the names, addresses and telephone numbers of your witnesses below.
Please describe how your privacy complaint could be resolved.
OMES may decide that your complaint does not violate the HIPAA Privacy Rule or any other applicable law or regulation, but another organization may be able to help you. Please choose one of the following: