Ontario County, NY · Ontario County
Health Information Privacy Complaint Form
This form lets a person report a concern about health information privacy rights to an Ontario County department.
At a glance
- Issued by
- City of Ontario County · Ontario County, Ontario County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- ontariocountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this form to describe a suspected violation of your health information privacy rights or someone else’s. It asks for contact details, the name of the person whose rights may have been violated, the County Department involved, dates, and a brief explanation. It also lets you request communication accommodations, such as an interpreter or large print.
Who needs it
A person who believes their health information privacy rights, or someone else’s, were violated by an Ontario County department can use this form.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This complaint form is signed and dated without a notary; the signer just signs and dates it.
How to submit this form
- 1
Download the Form
Download the Health Information Privacy Complaint Form PDF.
- 2
Complete the Form
Provide your contact details, describe the suspected violation, and answer whether you are filing for someone else.
- 3
Request Accommodations
If needed, select an accommodation and specify the requested language for an interpreter.
- 4
Sign and Submit
Sign and date the form, then submit it to the county department named on the form.
Frequently asked questions
- What does the Health Information Privacy Complaint Form ask for?
- It asks for contact information, whose health information rights may have been violated, the County Department involved, dates, and a brief description of the suspected violation.
- Who can file this complaint form?
- The form asks whether you are filing for someone else and, if so, whose health information rights you believe were violated.
- Do I need a notary for the Health Information Privacy Complaint Form?
- No. The form has signature and date lines but no notary block; the signer just signs and dates it.
- How do I submit the Health Information Privacy Complaint Form?
- Submit it to the county department named on the form; check the county website for current contact details.