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                "text": "Privacy Complaint",
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                "text": "Name: _____ Date: _____",
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                "text": "Please describe the nature of the complaint:",
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                "text": "Date of Occurrence: ___ Information Affected: ___",
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                "text": "Please name the entity that is the subject of the complaint:",
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                "text": "Signature Date",
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                "type": "TEXT",
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                "text": "Please state the reason(s) supporting the requested amendment:",
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            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 70.08,
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                "text": "Please mail this form to the University's Privacy Official at the following address:",
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            {
                "page": 1,
                "type": "TEXT",
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                "text": "Samantha Todd, APRN",
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                "text": "HIPAA Privacy Official",
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                "text": "Kentucky State University",
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                "text": "Student Health Services",
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                "text": "400 East Main Street",
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                "text": "Frankfort, KY 40601",
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            {
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                "location": {
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                "text": "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.",
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                "text": "You also may submit a written complaint to the appropriate Office of Civil Rights Regional Office.",
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