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File a HIPAA Complaint - Protected Health Information (PHI)

A complaint may be filed for an individual currently receiving services or for an individual that has received services from Division of Developmental Disabilities (DDD) in the past. You may file a Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) complaint if you believe any of the following has occurred:

A DDD Member’s protected health information was disclosed by DDD, or a business associate (Qualified Vendor Agency) of DDD, without your written authorization and no exception exists under the Privacy Rules (e.g., disclosure for treatment purposes);
A DDD Member’s protected health information was lost, stolen, improperly disposed of, or was involved in a hacking incident.
A DDD Member is entitled to a Notice of Privacy Practices and was not provided with one;
Your request to access protected health information was denied or was not provided in the time frame required by the Privacy Rules;
If DDD failed to provide a required accounting of disclosures within the time frame required by the Privacy Rules;
Your request to DDD to amend protected health information that was created by DDD was denied;
Your request for DDD to restrict protected health information was denied;
Your request to DDD for communication in an alternative format or alternate location was denied;
Any other Privacy violation.

Contact HIPAA

Contact for Privacy Information
Division	Name	Phone Number	Email Address
DDD	Doricela Dominguez	(602) 542-6869	[email protected]
DES	Jared Spurgeon	(480) 647-3108	[email protected]
RMAP	Asmeen Hamkar	(602) 542-6604	[email protected]

Check HIPAA FAQ for more information.

Your Contact Information

Last Name *

First Name *

Middle Initial

Email Address *

Telephone Number *

Ext.

Subject(s) of Allegation

Date of breach or date breach was discovered *

Month

Day

Year

Information about the person or business you are reporting who committed the potential breach. *

DDD Staff

Business/Provider/Contractor

DDD Staff First Name *

DDD Staff Middle Initial

DDD Staff Last Name *

Name of business: *

First Name of Business Contact *

Last Name of Business Contact *

Street Address *

City *

State *

Zip Code *

Telephone Number *

Ext.

Witness(es)

Do you know of other people who could provide information about this suspected breach? *

Yes

No

List all witnesses

Please provide first name, last name and contact information of any persons who could provide additional information about this suspected breach.

Allegation Summary

How many members were potentially affected? *

List the names of all persons involved in the potential breach *

Please provide detailed information about the potential breach. (Write clearly, objectively and in order of occurrence, without reference to the writer’s opinion.)

What happened Before the incident? *

What happened During the incident? *

What happened After the incident? *

For employees of the Division of Developmental Disabilities (DDD)

Are you an employee of DDD? *

Yes

No

Was the documentation able to be retrieved? *

Yes

No

N/A

What steps are being taken to prevent this from happening again? *

Leave this field blank

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Pursuant to Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) and other nondiscrimination laws and authorities, ADES does not discriminate on the basis of race, color, national origin, sex, age, or disability. Persons that require a reasonable modification based on language or disability should submit a request as early as possible to ensure the State has an opportunity to address the modification. The process for requesting a reasonable modification can be found at Equal Opportunity and Reasonable Modification.

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File a HIPAA Complaint - Protected Health Information (PHI)

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