Form55 - response from us please do complete those items...

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[ FORM 55 —Use the top of this page for your letterhead.] Is There a Problem? If you are not satisfied with your experiences in our office, we want to hear from you. If you have a problem with anything about our practice, first speak with one of our staff. If the problem is with your insurance, bills, or payment, talk to , who is our . If the prob- lem is with your therapy, talk to your therapist. If you believe there has been a violation of the confidentiality or the pri- vacy of your records, speak to our privacy officer, , to help us clarify and fix the situation. If you don’t know whom to talk to about a problem, ask our privacy officer for assistance. If you are still not satisfied or the problem continues ,please fill out this simple form so we can investigate it. We will try our best to fix it, and to repair any damage that has been done. Bringing a problem to our attention will not in any way limit your care here or cause us to take any actions against you. If you wish to remain anonymous, you do not have to fill in the lines marked with an asterisk (*). But if you want a
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Unformatted text preview: response from us, please do complete those items. Thank you. *Client’s name: *Date of birth: *Client’s address: *Phone: *Identification #: What is or was the problem? What would you like to see done about the problem? *Signature of client or his or her personal representative Date *Printed name of client or personal representative *Relationship to the client *Description of personal representative’s authority Note: If a name is given on the form, a response must be made to this person within 30 days from when you, the privacy officer, receive this form. Indicate action(s) taken on a separate page. Version # Privacy Officer Phone FORM 55. A sample complaint form. From The Paper Office. Copyright 2008 by Edward L. Zuckerman. Permission to photo-copy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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