Patient Privacy Complaint Form

This form is provided so that we may address your concerns with the privacy policies and procedures of our practice. We will confirm our receipt of your complaint within five (5) working days, and provide a more thorough response, if necessary, within 30 days. Please complete the following information.

Date:

Patient Name:

Patient Email Address:

Mailing Address:

where a response should be sent

Privacy Complaint:

please specify your concerns with our privacy policies/procedures

Response: (Internal use only)

the date a response was provided on

Your information will be encrypted.