Complaint Regarding Uses or Disclosures Of Health Information

This form is to be used to file a complaint with Whitehall Boca Raton regarding its privacy policies and procedures, and compliance with those policies and procedures or the Federal privacy rule.  When this form is complete, please return it to:  Jeanette De La Rosa, Information Privacy Officer, located in the Health Information Management Department.

Resident's Information
 

___________________________
Name

___________________________
Social Security Number

___________________________
Date of Birth

Requestor's Information
(if not the resident)

________________________
Name

________________________
Relationship to the Resident

________________________
Source of Legal Authority

Date of incident: _______________________/ or  [   ] the practice is ongoing

Time of incident: ______________________/ or    [   ] Not applicable

Please describe the practice or incident about which you wish to complain:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Name & Title of Person(s) Involved, If Known: _________________________

Please describe why you believe that this practice or incident was/is improper:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

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Please attach any documentation that supports your complaint to this form.

I certify that the information recorded above is true to the best of my knowledge, and that I have a good faith belief that such practice or incident is a violation of Federal laws regarding the handling of a resident 's health information or of the facility 's privacy policies and procedures.

____________________________

Signature

____________________________

Date

Whitehall Boca Raton, 7300 Del Prado South, Boca Raton, FL 33433
Phone: (561) 395-8824; Fax: (561) 395-8824