Name: _____ Date: _____
Telephone Number: ___
Please describe the nature of the complaint:
Date of Occurrence: ___ Information Affected: ___
Please name the entity that is the subject of the complaint:
Signature Date
Please state the reason(s) supporting the requested amendment:
Please mail this form to the University's Privacy Official at the following address:
Samantha Todd, APRN
HIPAA Privacy Official
Kentucky State University
Student Health Services
400 East Main Street
Frankfort, KY 40601
You may also submit the complaint electronically to samantha.todd@kysu.edu. A complaint must be filed within 180 days of when you knew or should have known of the circumstances that led to the complaint.
You also may submit a written complaint to the appropriate Office of Civil Rights Regional Office.