Health Information Privacy Complaint Form

Complaint Forms for Discrimination; Health Information Privacy Complaints

OMB: 0945-0002

IC ID: 190142

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Health Information Privacy Complaint Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Form 0945-0002hipcomplaintform 12-3-15 HH.pdf Yes Yes Fillable Fileable
Other-form 0945-0002 -HIP complaint form package-508R.pdf Yes Yes Fillable Fileable

Health Illness Prevention

 

25,299 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 25,299 0 15,013 0 0 10,286
Annual IC Time Burden (Hours) 18,974 0 11,259 0 0 7,715
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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