Health Information Privacy Complaint | Presbyterian Healthcare Services

If you believe your health information privacy rights or that of someone else have been violated, please fill out this form. The form will be submitted to the Presbyterian Healthcare Services Privacy Officer. If you have any questions, please call 505-923-6706

* = indicates required fields

Contact Information for Person Reporting the Complaint:

First & Last Name*

Address*

City*

State*

ZIP*

Phone Number*

Email*

Whose health information privacy rights do you believe were violated:*

Self Other

Describe What Happened:

1) Who (or what area of Presbyterian) do you believe violated your (or someone else’s) health information privacy rights? Please list all persons or areas involved:*

2) Please list all dates and approximate times you believe the violation occurred: *

3) Describe briefly what occurred and how and why do you believe your (or someone else’s) health information privacy rights were violated? Please be as specific as possible: *