Notice

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

 

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

Uses and Disclosures

 

Here some examples of how we might have to use or disclose your health care information:

 

1)      Your chiropractor or a staff member may have to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.

2)      Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services.

3)      Your chiropractor and members of the staff may need to use your health information, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.

4)      Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you.  164.520 (b)(1)(iii) (A).  If you are not at home to receive an appointment reminder, a message will be left on your answering machine.

 

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information.  If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

 

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time.

 

Our Privacy Pledge

 

We have and always will respect your privacy.  Other than the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.

 

Permitted uses and disclosures without your consent or authorization

 

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:

 

1)      We are permitted to use or disclose you health information if we are providing health care services to you based on the orders of another health care provider.

2)      We are permitted to use or disclose your health information if we provide health care services to you as an inmate.

3)      We are permitted to use or disclose you health information if we provide health care services to you in an emergency.

4)      We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.                    Page 1

 

5)      We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

 

Other than the circumstances described in the preceding examples, any other use or disclosure of your health information will only be made with your written authorization.

 

Your right to revoke your authorization

 

You may revoke your authorization to us at any time; however, your revocation must be in writing.  There are two circumstances under which we will not be able to honor your revocation request:

 

1)      If you have already released your health information before we receive your request to revoke your authorization.164.508(b)(5)(i)

2)      If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.  If you wish to revoke your authorization please write to us at

 

THERIOT FAMILY CHIROPRACTIC
ATTN:  Dawn Romero

612 Rue De Onetta, New Iberia, LA 70563

337-367-6649 Phone 337-367-8494 Fax

 

Your right to limit uses or disclosures

 

If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information.  We are not required to agree to your restrictions.  However, if we agree with your restrictions, the restriction is binding on us.  If we so not agree to your restrictions, you may drop your request or you are free to seek care form another health care provider.

 

Your right to receive confidential communication regarding your health information

 

We normally provide information about your health to you in person at the time you receive chiropractic services form us.  We may also mail you information regarding your health or about the status of your account.  We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home or, if you would like the information in a different form. To help us respond to your needs, please make any request in writing.

 

Your right to inspect and copy your health information

 

You have the right to inspect and/or copy your health information for six years form the date that the record was created or as long as the information remains in our files.

 

Your right to amend your health information

 

You have the right to request that we amend your health information for six years from the date that the record was created or as long as the information remains in our files.  We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.

                                                                                                                                                                Page 2

 

            Your right to receive an accounting of the disclosures we have made of your records

 

Louisiana law requires that we furnish you, upon your request, a copy of any information related in any way to you, which we have transmitted, to any company, or any public or private agency, or any person.

 

We may charge reasonable copying charges for this service which are set forth in the statutes as well as a handling charge and actual postage.

 

We may deny access to a record if we reasonably conclude that knowledge of the information contained in the record would be injurious to the health or welfare of the patient or could reasonably be expected to endanger the life or safety of any other person.

 

Your right to obtain a paper copy of this notice

 

If you have agreed to receive privacy notices by e-mail, you may request a paper copy of this notice at any time.

 

Our duties

 

We are required by law to maintain the privacy of your health information.  We are also requires to provide you with this notice of our legal duties and our privacy practices with respect to your health information.

 

We must abide by the terms of the notice while it is in effect.  However, we reserve the right to change the terms of our privacy notice.  If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail.  If we make a change in our privacy terms the change will apply for all of your health information in our files.

 

Re-disclosure

 

Information that we use or disclose may be subject to re-disclose by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                                                        Page 3

Notice of Privacy Practices for Protected Health Information

 

Your right to complain

 

You may complain to us or to the Secretary for Health and Human Services if you fell that we have violated your privacy rights.  We respect your right to file a complaint and will not take any action against you if you file a complaint.  While you may make an oral complaint at any time, written comments should be addressed to:

Theriot Family Chiropractic

612 Rue De Onetta

New Iberia, LA 70563

 

To contact us

 

If you would like further information about our privacy policies and practices please contact:

Theriot Family Chiropractic

ATTN:  Dawn

612 Rue De Onetta, New Iberia, LA 70563

337-367-6649 Phone

 

This notice is effective as of ___________________________.  This notice will expire seven years after the date upon which the record was created.  By signing below, I acknowledge that I have received a copy of this notice.

 

 

______________________________________                                _________________________________

Patient Name Printed                                                                         Date

 

 

 

______________________________________                                _________________________________

Patient Signature                                                                                  Authorized Provider Representative

 

 

______________________________________                                _________________________________

Personal representative printed                                                  Personal representative signature

 

 

 

______________________________________

Description of personal representative’s

Authority to act for the patient.

 

 

 

 

 

 

 

 

 

 

HIPAA Privacy

Policies and Procedures

 

Our Policy on Confidentiality

 

We are committed to maintaining the complete confidentiality of our patients’ health care information.  As part of our commitment to patient confidentiality:

 

            ►We will not discuss the names of our patients with anyone that is not part of our practice.

            ►All information about our patients and their health conditions will be used within our practice in a              professional manner.

            ►Patient information will never be provided to a third party unless we have the appropriate consent                 and/or authorization signed by the patient.

 

Should we ever inadvertently make a mistake regarding the confidentiality of a patient’s health information, we will immediately do everything possible to correct the error.

 

Procedures

 

There are many rules regarding the confidentiality of patient information.  While our policies and procedures try to anticipate how to comply with these rules, please remember that our first and most important responsibility is to the health needs of the patient.

 

Prior to seeing the doctor on the patient’s initial visit, the patient will complete the following forms:

 

            ►Terms of Acceptance

►Office Fee Schedule and Financial Policy

►Health History

 

When the patient has completed the forms, the responsible CA will review the forms for completeness and will explain and have the patient sign and date the following forms.

           

►Notice of Privacy Practices for Protected Health Information

            ►CAL Authorization Form

►Appointment Reminder Authorization Form

►Marketing Authorization Form

 

In the case of an emergency where the patient is seen by the doctor before he/she does not have the opportunity to complete their administrative paperwork before receiving services, the authorization forms must be signed and dated before that patient leaves the office.

 

While our initial explanation of each form will be abbreviated, we will always be happy to provide the patient with a full and complete explanation of any portion of our privacy policy.  Copies of our privacy policy will be provided free of charge to any patient who requests a copy.

 

Restrictions & Requests for Changes to a Patient Record

 

A patient may occasionally ask us not to send their health care information to certain health care providers or third party payers.  A patient might also ask us to make changes in their health care records.  If the patient requests a restriction for their consent or authorization forms or requests that we change their health care records please:

1)      Ask that the patient write down their request.  This is necessary to make sure that we know exactly what the patient is requesting so that the doctor and/or the office can make a decision on whether or not to honor the request.

2)      The patient should be told that the doctor and/or the office must review the request before you can agree to it.  Very nicely, let the patient know that the law has special requirements when a patient asks for a restriction and that you will let them know as soon as possible whether or not you can honor their restriction.

 

If we must deny the patient’s request to amend their file, we must give the patient a written explanation for our denial.  The explanation will have to be prepared by the doctor since the reason will undoubtedly concern the patient’s clinical information.  We have other requirements that must be part of the written explanation, so be sure to check the HIPAA Reference Guide before giving the explanation to the patient.

 

Documentation of any request from a patient is absolutely critical.  All of the written information we receive form the patient should be immediately laced in the patient’s file.  If we receive verbal requests from a patient, the date, time, and consent of the patient’s instruction should be written down and placed in the patient’s file.  Any information in the patient’s file that concerns privacy must be retained for six years from he date it was created.

 

Resolving conflicts between consents and authorizations

 

Should we receive a patient consent or authorization in the mail, the responsible CA must determine if the terms of the consent or authorization are different that the terms we use.  If so, we follow the more restrictive language unless we can obtain a new consent or authorization from the patient.  If the patient gives us instructions by telephone, the responsible CA will immediately make a written record of the patient’s instructions as well as the date and time of the call.  This information should be attached to the patient’s consent form.  A new written consent or authorization should be obtained from the patient as soon as they come in for their next treatment.

 

Authorizations

 

We must have our patients sign authorizations for all of the following activities:

 

►If we need help in obtaining reimbursement for patient’s care from CAL (Chiropractic            Association of Louisiana)

►If we use patient’s name in advertising in any kind.

►To call patient’s to remind them of appointment times.

►To use patient’s name in any type of testimonial.

►To put the patient’s name on an internal “thank you” board.

►To use pictures of a child for a “kids wall”.

►To send Reminder cards.

►To send Complimentary Birthday Adjustments.

►For our Toys for Tots Drive

►For our Food Drive

►For Camp heartland (Camp for kids with AIDS and HIV)

 

The patient cannot participate in the activity listed above unless we have a signed and dated authorization.

 

Insurance help form the CAL

 

It is our policy to have our patients sign the CAL Authorization Form before receiving services from us.  If a patient has not signed the CAL authorization form we must delete the following information form the EOB or insurance correspondence before sending it to the CAL:

           

●             Names

●            Addresses

●            All dates

●            Phone Numbers

●            Fax Numbers

●            E-mail addresses

●            Social security numbers

●            Medical record numbers

●            Health plan beneficiary numbers

●            Account numbers

●            URLs

●            Biometric identifiers, including finger and voiceprints

 

Internal security for patient information

 

All patient information should be properly stored when it is not being used for clinical or administrative purposed.  This includes those occasions when a staff person is away form their desk for lunch, or steps away from a work area to perform another task.  Patient files should not be left on the doctor’s desk unless there is a secure area for the files within the office or the doctor’s office is locked when it is not occupied.  The last person to leave at night should verify that all data is stored properly and that the building is properly locked.

 

While we are all part of a team, the law does not allow each member of our team to have complete access to all of the information about a patient.  Internal communications about patients and/or their health condition should be limited to those individuals whose job descriptions entitle them to have this information.  Please do everything possible to respect the privacy of our patients when discussing health information on the phone, with patient health care or billing information should be discussed with them in a private area.

 

All of our computer data must be backed up as part of our closing procedures each day.  Backup tapes should be stored in a secure, fireproof container.  Weekly and/or monthly backup tapes should be store in a secure, off site storage.

 

Limits on health care information

 

We must always limit the amount of a patient’s health care information that is disclosed to the “minimum necessary’ to accomplish the intended purpose.  When another provider requests the patient’s health care records, the “minimum necessary” rule does not apply and the entire clinical record may be sent.  When an insurance company requests records, it is likely that they will record may be sent.  When an insurance company requests records, it is likely that they will specify the dates for which they require records.  If the insurer is specific as to the dates of information they would like, we do not have to verify that this is the “minimum necessary” information.  If the insurance company does not specify the dates they need to review then only the clinical records that are related to the patient’s current problem should be sent.

 

Before any records are released to an attorney, we must have a signed release form the patient.  Because the HIPAA privacy laws require us to send the “minimum necessary” health information, the authorization form he patient must specifically stat the dates for which records should be sent.

 

The “minimum necessary” rules apply to us internally as well.  If a staff person is only entitled to have access to certain parts of the patient’s health information we must honor that restriction.  Our staff members are give access to a patient’s health information based on their job responsibilities.  If you have questions about what health information may be given t another staff person, please ask the doctor and/or the office manager.

 

The Patient’s Right to Access Their Health Records

 

A patient has the right to a copy of their health records at any time-even if they have an unpaid balance on their account.  A patient may not take the originals of their records or x-rays because the law requires that we retain them respectively, for six years and three years from the last date of service.

 

We should do everything possible to immediately comply with patient’s request for a copy of their records.  If we cannot give them a copy immediately we should explain the reason for the delay and let the patient know when their records can be picked up or, when they will be mailed by us.  In any event, however, Louisiana law requires that copies of such records should be provided “within a reasonable period of time, not to exceed fifteen days following the receipt of the request and written authorization.”

 

A patient may ask you to justify our fee for records.  If this question is asked please let the patient know that our fee for copying records is based on the statutes governing such charges in the state of Louisiana.

 

Providing information to patients about disclosures of their health records

 

A patient has a right to ask us for the information regarding the disclosures that have been made of their health information for the previous six years (after the compliance date) from the date of their request.  The most important thing to remember is that this does not include disclosures related to their treatment or disclosures made to the insurance companies or other third party payers.  This would primarily concern disclosures made to attorneys, for marketing purposes, or if we engaged in fund raising.  Because the HIPAA privacy laws require us to handle these requests in a special manner, please let the doctor and /or the office manager know whenever a patient requests information regarding the disclosures of their health information.

 

 

Requests to send information to another address

 

Occasionally a patient may ask us to send information to someplace other than their home or, to fax them their statements rather than mail them.  Please do everything possible to accommodate the patient’s request.  We do not have the right to know why the patient is making their request, so please do not ask.  If there is some reason why you think we cannot accommodate the patient, please discuss the request with the office manager or the doctor.

 

Deceased Patients

 

All of the privacy rules apply to deceased patients.  Before we can release any of their information, we must have an authorization from the deceased patient’s personal representative.

 

Complaints from patients

 

Naturally we want to do everything possible to avoid a complaint from a patient regarding our privacy policy.  If a patient asks you how to make a complaint, please tell them the following:

-         The complaint must name the doctor or staff person and describe what the patient believes the person did improperly.

-         The law requires that all complaints be in writing.

-         The complain must be files within 180 days of when the patient knew the problem occurred.

 

Please tell the patient filing a complain that we will do everything possible to resolve the problem.  Let them know that the doctor will be in touch with them as soon as possible.  If a patient files a complaint, it should be given to the doctor immediately.

 

Changes to our notice

 

Whenever we change our notice we will immediately replace the notice that is on public display and make the notice available to patients on request.  We will retain a copy of each of our notices for the six years required by the law.

 

HIPAA Disciplinary Guidelines

 

It is unfortunate, but it may be necessary to discipline an employee that violates a patient’s right to privacy or does not follow these policies and procedures.  We will do our best to understand any extenuating circumstances before we take disciplinary action against you.

 

Our disciplinary actions can include:

'            Warnings (oral)

'            Reprimands (written)

'            Probation

'            Demotion

'            Temporary suspension

'            Discharge of employment

'            Restitution of damages

'                    Referral for criminal prosecution.

 

Any disciplinary action will be documented in the employment file of the staff person.  The file will contain specific information including:

           

'            The date of incident

'            The name of the reporting party

'            The name of the person responsible for taking action

'                    Follow-up action taken

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chiropractic Assistant

Job Description

 

Distinguishing Characteristics:

 

  ★            Friendly

  ★       Enjoys meeting and speaking with people

  ★            Punctual

  ★            Organized

  ★       Familiar with the use of office equipment

  ★       Type with speed and accuracy

  ★            Computer skills

  ★            Comfortable with numbers

  ★       Ability to deal with more than one telephone call or person

  ★       Ability to deal with difficult patients or situations

  ★            Knowledge of Chiropractic

  ★       Ability to deal with patients of different backgrounds (ig. Age)

  ★       Good judgment

  ★            Knowledge of different types of insurance

  ★            Knowledge of insurance payment policies and practices

  ★            Negotiation skills

  ★            Assertive

  ★            Persistent

  ★            Planning skills

  ★       Ability to direct others

  ★       Time management skills

  ★       filing skills

 

Duties:

 

     ● Phone Responsibilities

● Schedule patients for treatment.            Limited access

● Explain the service offered by the practice.            No access

● Take messages for the doctor/s and other staff members.            No access

● Make reminder appointment calls to patients.            No access

● other duties as assigned.

 

     ● Inventory and purchasing

● Inventory forms, chemicals and supplies on the schedule established by the doctor.

● Purchase items as necessary following the doctor’s guidance on lead times and quotes.

● other duties as assigned.             Varies

 

     ● Patient interaction

● Greet patients.            No access

● Direct patients to appropriate treatment room.            No access

● Schedule future treatment.            Limited access

● Other duties as assigned.            Varies

 

 

     ● Patient treatment

● Take and process patient x-rays as assigned by doctor. Full access

● Obtain preliminary patient histories as assigned by the doctor.            Full access

● Obtaining patients height, weight, and blood pressure as assigned by the doctor.            Full access

● Apply physiological therapeutics as assigned by the doctor. Full access

● Apply massage therapy as assigned by the doctor.             Full access

● Records clinical documentation as dictated by doctor. Full access

 

     ● Administrative duties

● Assemble the clinical records necessary for the treatment of patient. Full access

● Provide a routing slip or other accounting document to record the services received by a patient   during the course of an office visit.            No access

● Transcribe doctor’s dictation.            Full access

● Sequence and file clinical documentation.             Full access

● Contact insurance companies or other third party payers for patient insurance benefit information.            Limited access

● Contact employers when necessary to obtain information about worker’s compensation claims.            Limited access

● Screen mail, telephone calls and visitors.            No access

● Purge patient files on schedule establish by doctor. Full access

● Prepare newsletter on schedule established by doctor. No access

● Explain the office policy regarding payment for services.                       No access

● Prepare correspondence for doctor.            Full access

● Contact Medicare as necessary to obtain guidance on their reimbursement policies.            No access

● Listen patiently to patient complaints and refer them to the appropriate staff person or doctor for resolution.            Limited access

● Attend programs as necessary to improve clinical/administrative skills.            No access

● Other duties as assigned by doctor.

 

     ● Billing

● Process routing slips of the accounting documents used to record patient services.  Limited access

● Enter data into computer for billing.            Limited access

● Bill for patient services on timetable established by doctor.            Limited access

● Prepare billing for mailing.                    Limited access

● File office copy of the HCFA 1500 appropriately.               Limited access

● Prepare patient statements.                   Limited access

● Prepare statements for mailings.            Limited access

● File office copy of statements appropriately.            Limited access

● Other duties as assigned by doctor.            Limited access

 

     ● Collections/Accounts receivable

● Collect for services from cash paying patients.            Limited access

● Collect applicable patient co-payment and/or deductibles on the timetable established by the doctor.             Limited access

● Follow-up with insurance companies on the status of unpaid claims.            Full access

● Follow-up with patients on the status of unpaid claims.            Limited access

● Provide clinical documentation as necessary to expedited payment of claims.             Limited access

● Keep documentation or records for all activities.            Same access as the activity

● other duties as assigned by doctor. Varies

 

     ● Accounting

● Apply payments form patients and insurers to patient accounts.            Limited access

● Make bank deposits on schedule established by doctor. No access

● Balance cash drawer on schedule established by doctor. No access

● Verify payroll data before each payroll date.     No access

● Prepare payroll.             No access

● Pay invoices on schedule established by doctor.              No access

● complete appropriate employment forms for new employees.            No access

● Arrange for benefits for new employees.            No access

● Make all state and federal tax and other required payments on a timely basis.            No access

● Prepare accounting reports on schedule established by doctor.              No access

● Answer patient inquiries as it relates to their account.             Limited access

● Prepare and review financial statements.            No access

● File state and federal tax forms.   No access

● Conduct periodic audits.            No access

● Other duties as assigned by doctor. Varies

 

     ● Inventory and purchasing

● Inventory forms, chemicals and supplies on the schedule established by the doctor.            No access

● Purchase items as necessary following the doctor’s guidance on lead times and quotes.  No access

● other duties as assigned.            Varies

 

     ● Office management

● Serve as the office Medicare Compliance manager.            Full access

● Serve as the office HIPAA contact and compliance manager.            Full access

● Train staff as necessary in the performance of their duties.      Full access

● Supervise the work of staff as assigned by the doctor.  Full access

● Set goals for the staff as assigned by the doctor. No access

● Attend programs to improve/enhance clinical and/or administrative skills.    Varies

● Prepare internal marketing information as requested by the doctor.            No access

● Make all of the preparations necessary for patient education programs.             No access

● Prepare and place employment ads as assigned by doctor.            No access

● Interview potential staff members.                     No access

● Design and revise policies and procedures for office staff.            No access

● Conduct periodic audits.             Full access

● Conduct performance reviews of employees work on schedule established by the doctor.            Full access

● Enforce disciplinary rules as established by the doctor.            Full access

● Make recommendations for payroll and/or benefit increases for staff members.              No access

● Manage the storage, processing and flow of paper and electronic records.            Full access

● Provide for the security for electronic and paper records.              No access

● Other duties as assigned by doctor. Varies

 

     ● Maintain the office

● Clean equipment/treatment rooms after each use.              No access

● Straighten office furniture as necessary.            No access

● Vacuum and dust office as necessary.            No access

● Empty waste receptacles as necessary.            No access

● Arrange reading material and treatment brochures as necessary.                    No access

● Clean bathrooms daily.    No access

● Tidy bathrooms as necessary.            No access

● Clean employee lunchrooms as necessary.            No access

● Change chemicals in x-ray unit as necessary.            No access

● Provide maintenance on office equipment as necessary.            No access

● Organize and maintain storage areas as necessary.            No access

● Change light bulbs as necessary.            No access

● Launder dressing gowns and other items as necessary.            No access

● Decorate office under guidelines established by the doctor.            No access

● Arrange grass cutting/snow plowing as necessary.            No access

● Arrange for carpet cleaning/painting or other office maintenance as necessary.            No access

● Other duties as assigned.            Varies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLAINT

 

Dr. Tina M. Theriot

612 Rue De Onetta

New Iberia, LA 70563

Telephone:  337-367-6649

 

PURPOSE:

 

 

1.      TO THE PERSON

 

You have the right to file a complaint with us about our privacy practices or our compliance with our Notice of Privacy Practices, our Privacy Policies and Procedures, or federal or state privacy rules or law.  We will investigate your complaint and give you our written answer.  We will not require you to give up any right you may have under federal or state privacy or other law to file your complaint, and filling your complaint will not cause us to treat you badly.  To use this right, please complete, sign and date Sections A and B below, then submit this complaint to us at: 

 

            Dr. Tina M. Theriot

            Theriot Family Chiropractic Center

            ATTN:  DAWN

            612 Rue De Onetta

            New Iberia, LA 70563

            Telephone:  337-367-6649

            Fax:  337-367-8494

            Email:  dawn@drtheriot.com

 

If you have any questions, or if you need more information or help to complete your complaint, please contact us at the location listed above.  You may also file a complaint with the United States Department of Health and Human Services.  For information about how to do that please contact us at the location listed above.

 

 

2.      SECTION A:  PERSON FILING A COMPLAINT

 

Your Name: _______________________________________________________________________

 

Your Telephone Number: ____________________________________________________________

 

Your Fax Number: _________________________________________________________________

 

Your Address: _____________________________________________________________________

 

Your E-mail Address: _______________________________________________________________

 

Your Patient Account Number: ________________________________________________________

 

Your Social Security Number: ________________________________________________________

 

COMPLAINT

 

 

3.      SECTION B:  PERSON’S COMPLAINT

 

a.       Please give a short, plain statement of your complaint:

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

 

b.      Please give a short, plain statement of how you would like your complaint to be solved.

 

            4.  PERON’S SIGNATURE

 

I certify that the statements made in this complaint are true and correct tot the best of my information and belief.

 

Signature ___________________________________              Date ­­­______/_____/______

                                                                                                                     Month / date / year

 

If this complaint is filed by a representative for the person who is filing the complaint, complete the following:

 

Person Representative’s Name: _______________________________________________________

                                                                                                Printed name

 

Relationship to the Person: ___________________________________________________________

 

 

 

 

YOU HAVE A RIGHT TO HAVE A COPY OF THIS COMPLAINT