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Unformatted text preview: response from us, please do complete those items. Thank you. *Clients name: *Date of birth: *Clients 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 representatives 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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- Spring '10