Liberty County Hospital & Nursing Home, Inc.
dba LIBERTY MEDICAL CENTER

PRIVACY COMPLAINT

NOTE: Liberty County Hospital & Nursing Home, Inc (doing business as Liberty Medical Center and Wheat Country Estate) will not retaliate against any patient, employee, or observer who registers a complaint concerning medical privacy matters of any kind. All complaints shall be investigated and resolved to the best possible conclusion. All matters shall be confidential. Signing this form is optional; however we may not be able to investigate the complaint fully without your cooperation.

DATE: ________________________

PATIENT NAME: ___________________________________

DESCRIPTION OF THE COMPLAINT

OPTIONAL: Signature of person filing complaint Date

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INVESTIGATOR’S COMMENTS:

ANALYSIS OF PROBLEM:

ACTION PLAN:

Investigator’s Signature Date

The complaint has been investigated and resolved to the best possible conclusion.

Privacy Officer Date