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U.S. Department of Health and Human Services
Office for Civil Rights
Complaint Portal: Civil Rights

Complaint Portal – File a Civil Rights Complaint
Form Approved: OMB No. 0945-0002
Expiration Date: 11/30/2022
To file a complaint, please enter information in the wizard pages below. A field with an asterisk (*) before it is a required field.
ComplainantComplaint DetailsAdditional InformationSignatureConsentReview and Submit
Please fill out and sign this Complainant Consent Form.
COMPLAINANT CONSENT FORM

The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has the authority to collect and receive material and information about you, including personnel and medical records, when they are relevant to its investigation of your complaint.

To investigate your complaint, OCR may need to reveal your identity or identifying information about you to persons at the entity or agency under investigation or to other persons, agencies, or entities. In some circumstances, OCR may refer your complaint to another government agency, as warranted.

The Privacy Act of 1974 protects certain federal records that contain personally identifiable information about you and, with your consent, allows OCR to use your name or other personal information, if necessary, to investigate your complaint.

Consent is voluntary, and it is not always needed in order to investigate your complaint; however, failure to give consent is likely to impede the investigation of your complaint and may result in the closure of your case.

Additionally, OCR may disclose information, including medical records and other personal information, which it has gathered during the course of its investigation in order to comply with a request under the Freedom of Information Act (FOIA) and may refer your complaint to another appropriate agency.

Under FOIA, OCR may be required to release information regarding the investigation of your complaint; however, we will make every effort, as permitted by law, to protect information that identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy.

OCR will use any applicable protections in that law to safeguard information which could identify you, or other individuals, or that, if released, could constitute a clearly unwarranted invasion of personal privacy. OCR may be required to release some information regarding the investigation of your complaint under the Freedom of Information Act (FOIA), however, information concerning your complaint which could reveal your identity is protected from disclosure to third party requesters under FOIA.

Please read and review the documents entitled, Notice to Complainants and Other Individuals Asked to Supply Information to the Office for Civil Rights (PDF) and Protecting Personal Informations in Complaint Investigations (PDF) for further information regarding how OCR may obtain, use, and disclose your information while investigating your complaint.

In order to expedite the investigation of your complaint if it is accepted by OCR, please read, sign, and return one copy of this consent form to OCR with your complaint. Please make one copy for your records.
As a complainant, I understand that in the course of the investigation of my complaint it may become necessary for OCR to reveal my identity or identifying information about me to persons at the entity or agency under investigation or to other persons, agencies, or entities.
I am also aware of the obligations of OCR to honor requests under the Freedom of Information Act (FOIA). I understand that it may be necessary for OCR to disclose general information which it has gathered as part of its investigation of my complaint, excluding personally identifiable information.
In addition, I understand that, as a complainant, I may be covered by the Department of Health and Human Services’ (HHS) regulations which protect any individual from being intimidated, threatened, coerced, retaliated against, or discriminated against because he/she has made a complaint, testified, assisted, or participated in any manner in any mediation, investigation, hearing, proceeding, or other part of HHS’s investigation, conciliation, or enforcement process.

* After reading the above information, please check ONLY ONE of the following boxes:

CONSENT: I have read, understand, and agree to the above and give permission to OCR to reveal my identity or identifying information about me in my case file to persons at the entity or agency under investigation or to other relevant persons, agencies, or entities during any part of HHS’ investigation, conciliation, or enforcement process.
CONSENT DENIED: I have read and I understand the above and do not give permission to OCR to reveal my identity or identifying information about me. I understand that this denial of consent is likely to impede the investigation of my complaint and may result in closure of the investigation.

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If you need help filing a civil rights, conscience and religious freedom, or health information privacy complaint, please email OCR at OCRMail or call 1-800-368-1019. We provide alternative formats (such as Braille and large print), auxiliary aids and services (such as a relay service), and language assistance.

If you need other information on this web site translated or provided in alternative formats, please email us at OCRMail.

U.S. Department of Health & Human Services – 200 Independence Avenue, S.W. – Washington, D.C. 20201
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