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HIPAA Privacy Complaint Form

OMES recognizes that an individual who believes that his or her privacy rights have been violated with respect to protected health information has the right to complain without fear of retaliation. If you believe that your privacy rights or the privacy rights of another have been violated, you may file a complaint in writing with OMES or with the Office for Civil Rights.

You may submit your mailed complaint to:
OMES HIPAA Privacy Officer
2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105

Your information
Contact preferences
If you answered "yes" to the previous question, please enter the person's name and telephone number (with area code).
If you answered "yes" to the previous question, what special accommodation needs to be made?
Disclosure consent

Please indicate your consent below.

I consent to my name being disclosed to investigate this complaint. (OMES will not divulge information about you in our investigation within the limits allowed in law.)
If I do not consent to my name being disclosed, I understand that not using my name may hinder OMES’ ability to complete the investigation.

Complaint information
Please include a specific date. If that date is not available, enter an approximate date.
If you answered "yes" to the previous question, whose health information privacy rights do you believe were violated? (Enter the person's first and last name).
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:

Filing a complaint with OMES is voluntary. Without the information provided above, the Privacy Officer may be unable to proceed with your complaint. We collect this information under the authority of the Privacy Rule issued pursuant to the Health Insurance Portability and Accountability Act of 1996. We will use this information to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form will be treated confidentially. Any information provided may be disclosed to the U.S. Department of Health and Human Services or to other state and federal agencies as required by law.
It is illegal for a covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the Privacy Rule. You are not required to use this form. You may also write a letter or submit a complaint electronically with the same information. Complaints must be filed within 180 days of when you knew the act occurred.