HIPAA Complaints

HIPAA Complaint Form

The information you provide here will remain confidential to the extent possible. However we may need to divulge information to investigate your claim.

Anyone may file a complaint. Members of the workforce may use this form to report violations of HIPAA by others in the workforce free from fear of retaliation.

Please remember do not enter any Protected Health Information (PHI) on this form.

If you have questions about this form, please email the Hillsborough County HIPAA Privacy Officer or call 1-800-466-5400.

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Who We Cover

Our HIPAA Privacy Officer is responsible for ensuring compliance of the following Hillsborough County departments/offices (click on the name of the department/office to see a description for that entity):

If you have a HIPAA complaint against your doctor, hospital, dentist, or any other agency/entity other than those listed above, you will need to contact them directly. We only provide compliance investigations for those Hillsborough County Administrator's departments listed above.

By checking the box below you verify that the complaint you want to file is against one of the Hillsborough County departments/offices listed above. Further, I understand that Hillsborough County cannot help with or investigate HIPAA complaints that are for any angencies/entities not on the list.

Verification*

I verify the complaint is against a Hillsborough County department/office that is listed

Anonymously File

You are free to file a HIPAA complaint anonymously. Please note, if you choose to file anonymously, once it is filed, you will not be able to follow up on the complaint.

In order for us to follow up with you, and for you to receive updates on the complaint, we will need your contact information, including your name, address, phone, and email.

Do you wish to file this complaint anonymously?*

Yes No

Personal Information

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Daytime Phone*

Evening Phone

Best way to reach you

Best time to reach you

Disclosure Consent

Consent to Disclose Your Name*

I consent to my name being disclosed to investigate this complaint. We will not divulge information about you in our investigation within the limits allowed in law. I do not consent to my name being disclosed. Not using your name may hinder our ability to complete the investigation.

Employment Information

Are you a Hillsborough County employee?*

Yes No

Employees may file complaints anonymously

Supervisors Name

Department

Complaint Resolution

Please describe how your privacy complaint could be resolved:

Save and Resume Later

Progress

All information submitted by this form or via email becomes a public record to the extent provided by law.

Under Florida law, e-mail addresses are public records.