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File a HIPAA Complaint - Protected Health Information (PHI)

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:

You/your child's protected health information was disclosed by DES workforce, or a business associate of (Department of Economic Security) DES, without your written authorization and no exception exists under the Privacy Rules (e.g., disclosure for treatment purposes);
You were entitled to a Notice of Privacy Practices from a DES covered component and were not provided with one;
Your request to DES or a Business Associate of DES to access protected health information was denied or was not provided in the time frame required by the Privacy Rules;
A DES covered component failed to provide a required accounting of disclosures within the time frame required by the Privacy Rules;
Your request to DES or a Business Associate of DES to amend protected health information to DES/the Business Associate created was denied;
Your request to DES or a Business Associate of DES to restrict protected health information was denied;
Your request to DES or a Business Associate of DES for communication in an alternative format or alternate location was denied;
Any other Privacy violation.

Check HIPAA FAQ for more information.

Subject(s) of Allegation

Date of potential breach *

Month

Day

Year

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

Staff

Business/Provider/Contractor

Last Name *

First Name *

Middle Initial

Name of business:

Street Address

City

State

Zip Code

Telephone Number *

Ext.

Category Type

Witness(es)

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

Yes

No

Allegation Summary

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

Please provide detail 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

How many members were potentially affected? *

Was the documentation able to be retrieved? *

Yes

No

N/A

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

Your Contact Information

Last Name *

First Name *

Middle Initial

Email Address *

Street Address

City

State

Zip Code

Telephone Number *

Ext.

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 accommodation based on language or disability should contact ADES’s Office of Equal Opportunity at [email protected]. Requests should be made as early as possible to ensure the State has an opportunity to address the accommodation.

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File a HIPAA Complaint - Protected Health Information (PHI)

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File a HIPAA Complaint - Protected Health Information (PHI)

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