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# Privacy Complaint

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.