TX HHS Form H0404. Privacy Complaint

The Texas Health and Human Services (HHS) Form H0404, Privacy Complaint, is a crucial document that helps individuals file complaints related to health information privacy rights violations. This form is typically used by individuals who believe their own or someone else's health information privacy rights have been breached.

This form requires the complainant to provide specific information, including their contact details and a brief description of how and why they believe a privacy violation occurred. The complainant must also indicate whether they are filing the complaint on behalf of someone else. If so, they must provide the person's date of birth, relationship to them, and a description of the alleged violation.

The completed form can be returned to the Texas Health and Human Services Privacy Office or filed with the Region VI, Office of Civil Rights, and U.S. Department of Health and Human Services. It is essential to note that HHS will not retaliate against individuals for filing a complaint. Key points to consider when using this form include:

• Filing a complaint if you believe your health information privacy rights have been violated
• Providing specific details about the alleged violation, including date of birth and relationship (if applicable)