Privacy Complaint Form

Please use this form to submit a complaint concerning the privacy and confidentiality of patient protected health information.

All complaints must be submitted in writing. You will not be penalized or retaliated against in any way for making a complaint to Dr Tracey Williams Dental Office.

Mail your completed form to :

Tracey Williams DMD
303 N Alabama St Suite 270
Indianapolis IN 46204
Your name*
Today's date*
Date Format: MM slash DD slash YYYY
Your address
Street Address City State ZIP Code
Patient's name*
Patient's date of birth*
Date Format: MM slash DD slash YYYY
Patient's previous name (if applicable)
Patient's address (if known)
Street Address City State ZIP Code
Date of the incident that is the reason for this complaint
Date Format: MM slash DD slash YYYY
Please give a brief explanation of your complaint, including dates and names/addresses of other people who maybe involved. Include copies of relevant materials you may have. If you need additional space, please include a separate page.
Complaint's signature
Date
Date Format: MM slash DD slash YYYY
Relationship to patient