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HIPPA Complaint Form

  1. Complaints regarding the use of your health information should be made to us and/or the Department of Health and Human Services at 205 Thurgood Marshall Boulevard, Kingstree, SC 29556.

  2. All complaints must be submitted in writing. There is no cost or penalty to you for filing a complaint.

  3. Signature Agreement

    I acknowledge receipt of this Notice of Privacy on this date.

  4. Signature Agreement

    Patient refused to sign the acknowledgment of receipt of the Notice of Privacy Policy. Patient was given a copy of the Notice, was offered the opportunity to review and ask questions.

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