Complaint Forms for Discrimination; Health Information Privacy Complaints

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved: OMB No. 0990-0269.
See OMB Statement on Reverse.

OFFICE FOR CIVIL RIGHTS (OCR)

CIVIL RIGHTS DISCRIMINATION COMPLAINT
YOUR FIRST NAME

YOUR LAST NAME

HOME PHONE (Please include area code)

WORK PHONE (Please include area code)

STREET ADDRESS
STATE

CITY
ZIP

E-MAIL ADDRESS (If available)

Are you filing this complaint for someone else?

No

Yes

If Yes, whose civil rights do you believe were violated?
FIRST NAME

LAST NAME

I believe that I have been (or someone else has been) discriminated against on the basis of:
Race / Color / National Origin

Age

Disability

Other (specify):

Religion

Sex

Who or what agency or organization do you believe discriminated against you or someone else?

PERSON/AGENCY/ORGANIZATION

STREET ADDRESS

CITY
ZIP

STATE

PHONE (Please include area code)

When do you believe that the civil right discrimination occurred?
LIST DATE(S)

Describe briefly what happened. How and why do you believe that you have been (or someone else has been) discriminated
against? Please be as specific as possible. (Attach additional pages as needed)

SIGNATURE

Please sign and date this complaint. You do not need to sign if submitting this form by email
because submission by email represents your signature.
DATE

Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your
complaint. We collect this information under authority of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of1973
and other civil rights statutes. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process
your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974.
Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible discrimination, for
internal systems operations, or for routine uses, which include disclosure of information outside the Department of Health and Human
Services (HHS) for purposes associated with civil rights compliance and as permitted by law. It is illegal for a recipient of Federal financial
assistance from HHS to intimidate, threaten, coerce, or discriminate or retaliate against you for filing this complaint or for taking any other
action to enforce your rights under Federal civil rights laws. You are not required to use this form. You also may write a letter or submit a
complaint electronically with the same information. To submit an electronic complaint, go to OCR’s web site at:
www.hhs.gov/ocr/civilrights/complaints/index.html. To mail a complaint see reverse page for OCR Regional addresses.
HHS-699 (6/08) (FRONT)

PSC Graphics (301) 443-1090

EF

The remaining information on this form is optional. Failure to answer these voluntary
questions will not affect OCR's decision to process your complaint.
Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)
Braille

Large Print

Cassette tape

Computer diskette

Electronic mail

TDD

Sign language interpreter (specify language):
Foreign language interpreter (specify language):

Other:

If we cannot reach you directly, is there someone we can contact to help us reach you?
FIRST NAME

LAST NAME

HOME PHONE (Please include area code)

WORK PHONE (Please include area code)

STREET ADDRESS

CITY

STATE

ZIP

E-MAIL ADDRESS (Ifavailable)

Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed)

PERSON/ AGENCY/ORGANIZATION/ COURT NAME(S)
DATE(S) FILED

CASE NUMBER(S) (If known)

To help us better serve the public, please provide the following information for the person you believe was discriminated against
(you or the person on whose behalf you are filing).
ETHNICITY (select one)

RACE (select one or more)

Hispanic or Latino

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Black or African American

White

Other (specify):

PRIMARY LANGUAGE SPOKEN (if other then English)

How did you learn about the Office for Civil Rights?
HHS Website/Internet Search
Fed/State/Local Gov

Family/Friend/Associate

Healthcare Provider/Health Plan

Religious/Community Org

Lawyer/Legal Org

Conference/OCR Brochure

Phone Directory

Employer

Other (specify):

To mail a complaint, please type or print, and return completed complaint to the OCR Regional Address based on the region
where the alleged violation took place. If you need assistance completing this form, contact the appropriate region listed below.
Region I - CT, ME, MA, NH, RI, VT
Office for Civil Rights, DHHS
JFK Federal Building - Room 1875
Boston, MA 02203
(617) 565-1340; (617) 565-1343 (TDD)
(617) 565-3809 FAX

Region V - IL, IN, MI, MN, OH, WI
Office for Civil Rights, DHHS
233 N. Michigan Ave. - Suite 240
Chicago, IL 60601
(312) 886-2359; (312) 353-5693 (TDD)
(312) 886-1807 FAX

Region II - NJ, NY, PR, VI
Office for Civil Rights, DHHS
26 Federal Plaza - Suite 3313
New York, NY 10278
(212) 264-3313; (212) 264-2355 (TDD)
(212) 264-3039 FAX

Region VI - AR, LA, NM, OK, TX
Office for Civil Rights, DHHS
1301 Young Street - Suite 1169
Dallas, TX 75202
(214) 767-4056; (214) 767-8940 (TDD)
(214) 767-0432 FAX

Region III - DE, DC, MD, PA, VA, WV
Office for Civil Rights, DHHS
150 S. Independence Mall West - Suite 372
Philadelphia, PA 19106-3499
(215) 861-4441; (215) 861-4440 (TDD)
(215) 861-4431 FAX

Region VII - IA, KS, MO, NE
Office for Civil Rights, DHHS
601 East 12th Street - Room 248
Kansas City, MO 64106
(816) 426-7277; (816) 426-7065 (TDD)
(816) 426-3686 FAX

Region IV - AL, FL, GA, KY, MS, NC, SC, TN
Office for Civil Rights, DHHS
61 Forsyth Street, SW. - Suite 3B70
Atlanta, GA 30303-8909
(404) 562-7886; (404) 331-2867 (TDD)
(404) 562-7881 FAX

Region VIII - CO, MT, ND, SD, UT, WY
Office for Civil Rights, DHHS
1961 Stout Street - Room 1426
Denver, CO 80294
(303) 844-2024; (303) 844-3439 (TDD)
(303) 844-2025 FAX

Region IX - AZ, CA, HI, NV, AS, GU,
The U.S. Affiliated Pacific Island Jurisdictions
Office for Civil Rights, DHHS
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 FAX

Region X - AK, ID, OR, WA
Office for Civil Rights, DHHS
2201 Sixth Avenue - Mail Stop RX-11
Seattle, WA 98121
(206) 615-2290; (206) 615-2296 (TDD)
(206) 615-2297 FAX

Burden Statement
Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for
reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of
Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201. Please do not mail complaint form to this address.
HHS-699 (6/08) (BACK)

COMPLAINANT CONSENT FORM
The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR)
has the authority to collect and receive material and information about you, including
personnel and medical records, which are relevant to its investigation of your complaint.
To investigate your complaint, OCR may need to reveal your identity or identifying
information about you to persons at the entity or agency under investigation or to other
persons, agencies, or entities.
The Privacy Act of 1974 protects certain federal records that contain personally identifiable
information about you and, with your consent, allows OCR to use your name or other
personal information, if necessary, to investigate your complaint.
Consent is voluntary, and it is not always needed in order to investigate your complaint;
however, failure to give consent is likely to impede the investigation of your complaint
and may result in the closure of your case.
Additionally, OCR may disclose information, including medical records and other personal
information, which it has gathered during the course of its investigation in order to comply
with a request under the Freedom of Information Act (FOIA) and may refer your complaint
to another appropriate agency.
Under FOIA, OCR may be required to release information regarding the investigation of
your complaint; however, we will make every effort, as permitted by law, to protect
information that identifies individuals or that, if released, could constitute a clearly
unwarranted invasion of personal privacy.
Please read and review the documents entitled, Notice to Complainants and Other
Individuals Asked to Supply Information to the Office for Civil Rights and Protecting
Personal Information in Complaint Investigations for further information regarding how
OCR may obtain, use, and disclose your information while investigating your complaint.
In order to expedite the investigation of your complaint if it is accepted by OCR,
please read, sign, and return one copy of this consent form to OCR with your
complaint. Please make one copy for your records.
•

As a complainant, I understand that in the course of the investigation of my
complaint it may become necessary for OCR to reveal my identity or identifying
information about me to persons at the entity or agency under investigation or to
other persons, agencies, or entities.

Complaint Consent Form

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•

I am also aware of the obligations of OCR to honor requests under the Freedom of
Information Act (FOIA). I understand that it may be necessary for OCR to disclose
information, including personally identifying information, which it has gathered as
part of its investigation of my complaint.

•

In addition, I understand that as a complainant I am covered by the Department of
Health and Human Services’ (HHS) regulations which protect any individual from
being intimidated, threatened, coerced, retaliated against, or discriminated against
because he/she has made a complaint, testified, assisted, or participated in any
manner in any mediation, investigation, hearing, proceeding, or other part of HHS’
investigation, conciliation, or enforcement process.

After reading the above information, please check ONLY ONE of the following boxes:
CONSENT: I have read, understand, and agree to the above and give permission
to OCR to reveal my identity or identifying information about me in my case file to
persons at the entity or agency under investigation or to other relevant persons, agencies,
or entities during any part of HHS’ investigation, conciliation, or enforcement process.
CONSENT DENIED: I have read and I understand the above and do not give
permission to OCR to reveal my identity or identifying information about me. I
understand that this denial of consent is likely to impede the investigation of my
complaint and may result in closure of the investigation.

Signature:

Date:

*Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.

Name (Please print):
Address:
Telephone Number:

Complaint Consent Form

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NOTICE TO COMPLAINANTS AND OTHER
INDIVIDUALS ASKED TO SUPPLY INFORMATION
TO THE OFFICE FOR CIVIL RIGHTS
Privacy Act
The Privacy Act of 1974 (5 U.S.C. §552a) requires OCR to notify individuals whom it
asks to supply information that:
— OCR is authorized to solicit information under:
(i) Federal laws barring discrimination by recipients of Federal financial assistance on
grounds of race, color, national origin, disability, age, sex, religion under programs and
activities receiving Federal financial assistance from the U.S. Department of Health and
Human Services (HHS), including, but not limited to, Title VI of the Civil Rights Act of
1964 (42 U.S.C. §2000d et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
§794), the Age Discrimination Act of 1975 (42 U.S.C. §6101 et seq.), Title IX of the
Education Amendments of 1972 (20 U.S.C. §1681 et seq.), and Sections 794 and 855 of
the Public Health Service Act (42 U.S.C. §§295m and 296g);
(ii) Titles VI and XVI of the Public Health Service Act (42 U.S.C. §§291 et seq. and 300s
et seq.) and 42 C.F.R. Part 124, Subpart G (Community Service obligations of HillBurton facilities);
(iii) 45 C.F.R. Part 85, as it implements Section 504 of the Rehabilitation Act in programs
conducted by HHS; and
(iv) Title II of the Americans with Disabilities Act (42 U.S.C. §12131 et seq.) and
Department of Justice regulations at 28 C.F.R. Part 35, which give HHS "designated
agency" authority to investigate and resolve disability discrimination complaints against
certain public entities, defined as health and service agencies of state and local
governments, regardless of whether they receive federal financial assistance.
(v) The Standards for the Privacy of Individually Identifiable Health Information (The
Privacy Rule) at 45 C.F.R. Part 160 and Subparts A and E of Part 164, which enforce the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C.
§1320d-2).
OCR will request information for the purpose of determining and securing compliance
with the Federal laws listed above. Disclosure of this requested information to OCR by
individuals who are not recipients of federal financial assistance is voluntary; however,
even individuals who voluntarily disclose information are subject to prosecution and
penalties under 18 U.S.C. § 1001 for making false statements.
Additionally, although disclosure is voluntary for individuals who are not recipients of
federal financial assistance, failure to provide OCR with requested information may
preclude OCR from making a compliance determination or enforcing the laws above.

Notice to Complainants and Other Individuals

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OCR has the authority to disclose personal information collected during an investigation
without the individual’s consent for the following routine uses:
(i) to make disclosures to OCR contractors who are required to maintain Privacy Act
safeguards with respect to such records;
(ii) for disclosure to a congressional office from the record of an individual in response to
an inquiry made at the request of the individual;
(iii) to make disclosures to the Department of Justice to permit effective defense of
litigation; and
(iv) to make disclosures to the appropriate agency in the event that records maintained by
OCR to carry out its functions indicate a violation or potential violation of law.
Under 5 U.S.C. §552a(k)(2) and the HHS Privacy Act regulations at 45 C.F.R. §5b.11
OCR complaint records have been exempted as investigatory material compiled for law
enforcement purposes from certain Privacy Act access, amendment, correction and
notification requirements.
Freedom of Information Act
A complainant, the recipient or any member of the public may request release of OCR
records under the Freedom of Information Act (5 U.S.C. §552) (FOIA) and HHS
regulations at 45 C.F.R. Part 5.
Fraud and False Statements
Federal law, at 18 U.S.C. §1001, authorizes prosecution and penalties of fine or
imprisonment for conviction of "whoever, in any matter within the jurisdiction of any
department or agency of the United States knowingly and willfully falsifies, conceals or
covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or
fraudulent statements or representations or makes or uses any false writing or document
knowing the same to contain any false, fictitious, or fraudulent statement or entry".

Notice to Complainants and Other Individuals

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PROTECTING PERSONAL INFORMATION IN
COMPLAINT INVESTIGATIONS
To investigate your complaint, the Department of Health and Human Services’ (HHS)
Office for Civil Rights (OCR) will collect information from different sources. Depending
on the type of complaint, we may need to get copies of your medical records, or other
information that is personal to you. This Fact Sheet explains how OCR protects your
personal information that is part of your case file.
HOW DOES OCR PROTECT MY PERSONAL INFORMATION?
OCR is required by law to protect your personal information. The Privacy Act of 1974
protects Federal records about an individual containing personally identifiable information,
including, but not limited to, the individual’s medical history, education, financial
transactions, and criminal or employment history that contains an individual’s name or
other identifying information.
Because of the Privacy Act, OCR will use your name or other personal information with a
signed consent and only when it is necessary to complete the investigation of your
complaint or to enforce civil rights laws or when it is otherwise permitted by law.
Consent is voluntary, and it is not always needed in order to investigate your complaint;
however, failure to give consent is likely to impede the investigation of your complaint
and may result in the closure of your case.
CAN I SEE MY OCR FILE?
Under the Freedom of Information Act (FOIA), you can request a copy of your case file
once your case has been closed; however, OCR can withhold information from you in
order to protect the identities of witnesses and other sources of information.
CAN OCR GIVE MY FILE TO ANY ONE ELSE?
If a complaint indicates a violation or a potential violation of law, OCR can refer the
complaint to another appropriate agency without your permission.
If you file a complaint with OCR, and we decide we cannot help you, we may refer your
complaint to another agency such as the Department of Justice.
CAN ANYONE ELSE SEE THE INFORMATION IN MY FILE?
Access to OCR’s files and records is controlled by the Freedom of Information Act
(FOIA). Under FOIA, OCR may be required to release information about this case upon
public request. In the event that OCR receives such a request, we will make every effort,
Protecting Personal Information

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as permitted by law, to protect information that identifies individuals, or that, if released,
could constitute a clearly unwarranted invasion of personal privacy.
If OCR receives protected health information about you in connection with a HIPAA
Privacy Rule investigation or compliance review, we will only share this information with
individuals outside of HHS if necessary for our compliance efforts or if we are required to
do so by another law.
DOES IT COST ANYTHING FOR ME (OR SOMEONE ELSE) TO OBTAIN A
COPY OF MY FILE?
In most cases, the first two hours spent searching for document(s) you request under the
Freedom of Information Act and the first 100 pages are free. Additional search time or
copying time may result in a cost for which you will be responsible. If you wish to limit
the search time and number of pages to a maximum of two hours and 100 pages; please
specify this in your request. You may also set a specific cost limit, for example, cost not
to exceed $100.00.
If you have any questions about this complaint and consent package,
Please contact OCR at http://www.hhs.gov/ocr/office/about/contactus/index.html
OR
Contact your OCR Regional Office
(see Regional Office contact information on page 2 of the Complaint Form)

Protecting Personal Information

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