Submitting Privacy Violations

If you feel your (or someone else's) health information privacy has been violated, please contact the Privacy Officer immediately at (205) 349-3250 ext. 3029. As an option, you may complete the information below and forward it to the Privacy Officer. Starting with the date you became aware of alleged privacy violation, you have 180 days to report it.

* First Name of Complainant:
* Last Name of Complainant:
* Address of Complainant:
* City of Complainant:
* State of Complainant:
* Zip of Complainant:
* Telephone Number of Complainant:
Email Address of Complainant:
Name of person you believe violated yours (or someone else's) health information privacy rights:
* Whatley Health Service Location violation occurred:
* Brief description of what happened. How, why and when do you believe your (or someone else's) health information privacy rights were violated?:
Any other relevant information:
Note: If you are filing a complaint on someone else's behalf, also provide the name of the person on whose behalf you are filing.