Lummi Compliance Complaint Form

Lummi Health Care Compliance Complaint

Fill out the form to contact the Compliance Office.

Complaints must be turned in turned into the Health Care Compliance Office electronically or on paper, filed within 180 days of the violation, retaliation is prohibited. How, when, and why must be answered.

If you have an immediate need to contact LIBC Staff, please call the Main Line at (360)312-2000

Patient Complaint Staff Complaint

Reporter First Name

Reporter Last Name

Reporter Phone

Reporter Email

Are you filing this complaint for someone else?

First Name *

Last Name *

Phone *

Who (or what agency or organization) do you believe violated your (or someone else’s) health information privacy rights?

HipaaViolationType

When do you believe that the violation of health information privacy rights occurred?

Describe briefly what happened. How and why do you believe your (or someone else’s) health information privacy rights were violated? Be as specific as possible.

Filing a complaint is voluntary. However, without the information requested above, we may be unable to proceed with your complaint. Information submitted on this form is treated confidentially. To investigate your complaint, we may need to reveal your identity or identifying information about you to persons at the person or entity under investigation or to other persons, agencies, or entities. Names and other identifying information about individuals are disclosed when it is necessary for investigation of possible health information privacy violations, for purposes associated with health information privacy compliance, and as permitted by law. It is illegal for a covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under HIPAA. You are not required to use this form. You may also write a letter, or contact Krista Jo Mahle at 360-312-2314.

Signing Date

Signature