Appendix ‘A’ Form to File a Privacy Violation Complaint
This organization values the privacy and confidentiality of your protected health information and committed to ensuring protection of such information
In case you have reasons to believe that the privacy of your PHI has been compromised you may kindly file a complaint or provide feedback through this form. You are assured of confidentiality in processing this complaint and also no acts of intimidation from any members of the workforce
Details of the incident/practice leading to violation of privacy rights:
Name :
Phone No:
Signature:
Date :
