Thank you for submitting a complaint.
This complaint cannot be processed until the client completes and submits the Records Release and Confidentiality Form.
There are two options.
- You may direct the client to the form on this web page so they can fill it out.
- They may print this pdf file, complete it fully, sign, and submit it as directed.
NARM must receive either this online form or the pdf form emailed or faxed within two weeks of your initial complaint.
Before completing any forms, we’d like you to understand the following very important information.
The Client’s Rights
You have the right to:
- Receive a list of those with whom we’ve shared information.
- Ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-?based fee if you ask for another one within 12 months.
- Receive a copy of this privacy notice.
- Request for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
- File a complaint if you feel your rights are violated.
- You may contact us and complain if you feel we have violated your rights.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
Investigation or Litigation?
NARM will not begin the processes of Complaint Review or Grievance Mechanism with a CPM or applicant who is also facing regulatory investigation, or civil or criminal litigation related to midwifery care. If a CPM faces such regulatory investigation or civil or criminal litigation, the timeline for receiving complaints is extended. In order to proceed with the Complaint Review or Grievance Mechanism processes, NARM must receive a formal complaint against the CPM within one year of the conclusion of regulatory investigation or litigation.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, through our office, and on our web site.
Other Instructions for Notice
This notice is effective as of 7-6-2018.
Please direct all question to NARM Information at 888-842-4784 ext. 1 or email firstname.lastname@example.org.
We never market or sell personal information.