Home > Privacy Complaint FormPrivacy Complaint FormComplaint form Incident Type: HIPAA/Pt healthcare privacy concern disclaimer PLEASE READ**use this form if you believe a patient’s protected healthcare information, including: name, pictures, test results, information on any medical condition or treatments received, appointment information, etc. was shared with someone outside of their direct care team or with someone who should not have access to any patient information.disclaimer confirmation * I have read this disclaimer Date/time incident occurred Time 121234567891011 : 000510152025303540455055 AMPM Location of incident (CAIHC, rural clinic, etc.) Do you wish to report anonymously? * Yes No Paragraph **You may report anonymously, be aware that any information you do not provide in this report may limit our ability to investigate your claims, if you chose to submit anonymously please be as detailed as possible. disclaimer confirmation * I have read this disclaimerReporter Name Reporter Name First First Last Last Reporter email Reporter phone Affected patient *required* Name(s) * Medical record number of person affected (if known) Contact information of person affected (optional) Parties involved Witnesses TCC employees Describe the event * Acknowledgement disclaimer By submitting this form, you acknowledge that the information contained will be forwarded to our Compliance Division for investigation. You may be contacted by a TCC Compliance representative to discuss this complaint. To discuss this complaint further you may contact TCC’s Privacy Officer at (907) 452-8251 ext. 3183.disclaimer confirmation * I have read this disclaimer reCAPTCHA Submit If you are human, leave this field blank.
