Name:__________________________________________________________________
Address:________________________________________________________________
Telephone: ____________________________ Date of Birth:______________________

Please describe the nature of the complaint including dates of occurrence.  Please name the DPH program, Bureau, or any individuals involved in your complaint.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________
Your Signature or Signature of Personal Representative   	   Date	
                                  	
_____________________________________   
Print Name	

Indicate relationship of person signing this form to the individual who is the subject of the information disclosed.
___ Person signing is the individual
___ Person signing is the Personal Representative authorized to make health care decisions for the individual. Describe the authority:______________________________

Please mail this form to: 			You may also contact:
Privacy Office					Office for Civil Rights
Massachusetts Dept. of Public Health	US Dept. of Health and Human Services
250 Washington St.				Government Center
Boston, MA 02108				J.F. Kennedy Federal Building-Room 1875
						Boston, MA 02203
				Voice Phone (617) 565-1340
Fax (617) 565-3809     TDD (617) 565-1343