Health Information Privacy and Security Complaint Form

Health Information Privacy and Security Complaint Process

The Health Insurance Portability and Accountability Act (HIPAA) allows individuals to file complaints regarding their health information privacy rights.

The HIPAA Compliance Program of Fairfax County Government investigates and responds to complaints from, or on behalf of residents who have received any health care services from Fairfax County Government agencies, Fairfax County Government employees, and retirees participating in the Health Plan administered by the County's Department of Human Resources' Benefits Division.

Complaints must be submitted within 180 days from the date of alleged infraction. Complaints are accepted for violations related to the privacy and security of individual’s protected health information (PHI). PHI is individually identifiable health information in any form or media, whether electronic, paper, or oral.

An investigation will be conducted once the complaint is received to determine if an alleged action or violation fails to comply with the HIPAA Privacy or Security Rules.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights; 800-537-7697;;   ;

Submitting the Complaint

The complaint form should be fully completed. Please provide as much information as requested in each of the fields within the form. Your detailed comments will greatly assist with the process. You may be contacted by the Fairfax County HIPAA Compliance Officer for additional information and follow up.

To file a complaint:

• You must have received health care services from a Fairfax County government agency or affiliated program, which includes the Fairfax County Health Department, the Fairfax County Fire and Rescue Department, and the Fairfax/Falls Church Community Services Board
• You are a participant in a Fairfax County government Health Plan
• Indicate your status by checking the appropriate box below (required)

Please select one category before you go to the complaint form:


Health Insurance Complaints

All other complaints related to health insurance coverage must be directed to your health insurance company or the Virginia State Corporation Commission, Bureau of Insurance, 877-310-6560;

The Fairfax County government HIPAA Compliance Program does not provide legal or medical advice. The HIPAA Compliance Program does not regulate health insurance premiums, health-care provider service charges, or quality of care issues.