Form Center

2. First Name
3. Last Name
5. Home Phone
6. Work Phone
7. Cell Phone
9. Email Address
11. Address
13. City
14. State
15. Zip Code
17. Are You Filing This Complaint for Someone Else?

    1. Yes
    2. No
18. First Name
19. Last Name
21. Describe briefly what happened. How and why do you believe your (or someone else’s) health information privacy rights were violated, or the privacy rule otherwise was violated?*

    Please do not provide specific health information details in this area. A staff member will contact you for detailed information regarding your complaint.

23. When do you believe that the violation of health information privacy rights occurred?
    When do you believe that the violation of health information privacy rights occurred?
25. Which County of Onslow Department (s) does this complaint involve?

    1. Onslow County Emergency Services
    2. Onslow County Human Resources
    3. Onslow County Department of Social Services

    1. Onslow County Health Department
    2. Onslow County Senior Services
27. Electronic Signature Agreement*

    By checking the "I agree" box below, you acknowledge your private health information may be shared with the covered entity for purposes of investigating this complaint.

    1. I agree
29. Electronic Signature*
Leave This Blank:


31. Submit

* indicates a required field