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HIPAA Privacy Complaint Form

  1. This form may be used to report HIPAA privacy incidents. Filing a complaint is voluntary. However, without the information requested below, we may be unable to fully investiage your complaint.

    Please complete all applicable fields. You will receive a response from staff within two business days.

    You may also call Kayla Wharton at 301-600-1308 to report a HIPAA incident.

  2. Are you filing a complaint for someone else?*
  3. If yes, whose privacy rights do you think were violated?
  4. Types of unsecured Personal Health Information involved in the breach.

    Please check all that apply.

  5. Leave This Blank:

  6. This field is not part of the form submission.