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Augusta Cardiology Clinic

POLICY 12.2

COMPLAINT FORM

Our practice values the privacy of its patients and is committed to operating our practice in a manner that promotes patient confidentiality while providing high quality patient care.

If the staff at the practice has in any way given you the impression that they are not protecting your right to privacy, we want you to notify us. Please be assured that your complaint will be kept confidential. Please use the space provided below to describe your complaint. It is our intent to use this feedback to better protect your rights to patient confidentiality.

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Name of Patient

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Signature of Patient



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Date

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Phone Number
To file a complaint with the Office of Civil Rights pursuant to §160.306 please send in writing to the following address:
  The U. S. Department of Health & Human Services
Office of Civil Rights
Hubert H. Humphrey Building
200 Independence Avenue
Washington, D.C. 20201
Web Site: www.hhs.gov/ocr/hipaa/