Patients have to right to file a formal complaint if they feel we have not adequately protected their privacy. This complaint must be submitted in writing to Dr. Elliott, the privacy officer, or may be submitted directly to the U.S. Department of Health and Human Services Secretary. The complaint must be submitted within 180 days of the event of concern. The privacy officer is responsible for the investigation and resolution of the complaint. The practice must maintain a record of the complaint and the resolution, if applicable, for six years.

    I, _______________________________________, would like to make a complaint about the privacy practices and/or procedures at Brett Elliott, M.D. P.A. The following is my statement: (Please include specific details such as specific personnel involved and the date and location of the event of concern to you.)

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Signature of patient: ______________________________________ Date:____________