Questions or Complaints Clause Samples

Questions or Complaints. If you have a question or complaint about your privacy rights, please contact ▇▇. ▇▇▇▇ by phone at ▇▇▇-▇▇▇-▇▇▇▇ or by mail at 4971 East I-▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇; ▇▇▇▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇. If ▇▇. ▇▇▇▇ is unable to resolve your complaint to your satisfaction, you may send a written complaint to the Office of Civil Rights, U.S. Department of Health & Human Services, ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇., ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇.▇. 20201. We will not retaliate against you for filing a complaint. Signature Date Printed Name Additional Signature (if needed) Date Printed Name

Questions or Complaints. You can direct any questions or complaints about the use or disclosure of your personal data to us at ▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇. We will investigate and attempt to resolve any complaints or disputes regarding the use or disclosure of personal data within 45 days of receiving your complaint.

Questions or Complaints. If you have a question or complaint regarding the Site, please contact us at: ▇▇▇▇@▇▇▇▇▇-▇▇▇▇▇.▇▇

Questions or Complaints. If you have questions about this notice or think that we have not protected your private health information and you wish to complain about it, please contact: ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Ph.D. at (▇▇▇) ▇▇▇-▇▇▇▇. You can also complain to the Federal Government by writing to the: Office for Civil Rights U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Room 509F, HHH Building Washington, D.C. 20201-0004 Or by calling the Office for Civil Rights at (▇▇▇) ▇▇▇-▇▇▇▇ By signing this form, you are acknowledging that you have received a copy of this notice (NOTICE OF USE OF PRIVATE HEALTH INFORMATION) Patient Signature Date Parent/Guardian Signature (if necessary) Date Thank you for choosing Pacific Pain and Wellness Group for your medical care. Our goal is to provide you with the highest quality of medical care and service. We feel it is helpful and important that you understand our billing process. We are happy to ▇▇▇▇ your insurance for any services provided at our offices. However, this is a courtesy service to you and you are responsible for any costs incurred during your course of treatment. Each patient must complete the Patient Information Record which includes all demographic information including your insurance. We must have this information completed before you see the doctor on your first visit.

Questions or Complaints. If you have questions or complaints about our broadband Internet access service you should first visit our website at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If the question or complaint is not resolved on the web, you may contact one of our customer service representatives at ▇ (▇▇▇) ▇▇▇-▇▇▇▇. We find that most customer concerns or disputes can be resolved through our customer service representatives. If the question or complaint is still not resolved you may contact Cellular One’s Chief People Officer at ▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. However, any customer disputes that cannot be resolved without third-party intervention will be resolved by binding arbitration in accordance with the terms of our service agreement, which can be found here at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇.

Questions or Complaints. If you have questions or complaints about this Agreement, please contact us at: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or (▇▇▇) ▇▇▇-▇▇▇▇, Monday through Friday, except holidays, from 8:00 a.m. to 5:00 p.m. EST.

Questions or Complaints. If you have questions about this notice, or believe that your privacy rights have been violated, please contact our Privacy Officer, ▇▇▇▇▇▇ ▇▇▇▇▇ at ▇-▇▇▇-▇▇▇-▇▇▇▇ or by email at privacy.officer@ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. You have the right to file a written complaint with us or directly to the secretary of Health and Human Services. You should know that there would be no retaliation for your filing a complaint. Effective Date: January 1, 2003 To publish the policies and procedures to implement the requirements of the Final HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule with regard to obtaining the patient’s acknowledgment of receipt of a copy of MCC’s Notice of Health Information Privacy Practices. The Privacy Rule (as amended at section 164.520(c)(2)(ii)) states: "Except in an emergency treatment situation, [health care providers having a direct care rela- tionship with a patient] must make a good faith effort to obtain a patient’s written acknowledg- ment of receipt of the notice provided in accordance with paragraph (c)(2)(i) of this section, and if not obtained, document its good faith efforts to obtain such acknowledgment and the reason why the acknowledgment was not obtained." All MCC physicians and health care providers are required by HIPAA to provide each patient with a copy of MCC’s Notice of Health Information Privacy Practices and to make a “good faith effort” to obtain the patient’s written acknowledgment that they have been provided with a copy of the Notice.

Questions or Complaints. If you have a question or a complaint about this Privacy Notice or information handling processes, you can send us an email to ▇▇▇▇@▇▇▇▇▇▇▇▇▇▇.▇▇▇

Questions or Complaints. If you have a question or complaint regarding the Website, please send an e-mail to ▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. You may also contact us by writing to ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, Temple City, CA, 91780, or by calling us at (▇▇▇) ▇▇▇-▇▇▇▇. Please note that e-mail communications will not necessarily be secure. Accordingly, you should not include credit card information, personal information, personal health information, or other sensitive information in your e-mail correspondence with us. California residents may reach the Complaint Assistance Unit of the Division of Consumer Services of the California Department of Consumer Affairs by mail at ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇., ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇, or by telephone at (▇▇▇) ▇▇▇-▇▇▇▇ or (▇▇▇) ▇▇▇-▇▇▇▇.