Complaint Forms for Civil Rights and Conscience; Health Information Privacy and Security Complaints

OMB 0945-0002

OMB 0945-0002

Individuals may file written complaints with the Office for Civil Rights when they believe they have been discriminated against by programs or entities that receive Federal financial assistance from HHS or if they believe that, on or after April 14, 2003, their right to the privacy of protected health information has been violated. The complaint forms in this PRA submission provide the basic information needed by OCR to allow initial processing of such complaints.

The latest form for Complaint Forms for Civil Rights and Conscience; Health Information Privacy and Security Complaints expires 2022-11-30 and can be found here.

OMB Details

Complaint Forms for Discrimination; Health Information Privacy Complaints

Federal Enterprise Architecture: Health - Health Care Services


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