Common use of For More Information or to Report a Problem Clause in Contracts

For More Information or to Report a Problem. If you have any questions about your rights, my duties, or my practices and procedures regarding protected health information, please contact the Secretary of the Department of Health and Human Services at 000 Xxxxxxxxxxxx Xxxxxx, X.X. Washington, D.C. 20201 or by calling (000) 000-0000. Complaints to the Secretary must be filed in writing on paper or electronically and must be made within 180 days of when you became aware of, or should have been aware of, the incident giving rise to your complaints. By law, you cannot be penalized for filing a complaint. Your signature below indicates that you have read this document and have had the opportunity to have any questions answered to your satisfaction. Signed Date Signature of Patient Signed Date Signature of Parent, Guardian or Personal Representative (if applicable) Signed Date Parker Pediatrics & Adolescents Psychology Parker Pediatrics & Adolescents, P.C. Page 2 of 2 Rev 07/18 00000 Xxxxxxxxx Xxx, Xxxxx 000 Parker, Colorado 80138 Telephone: 000-000-0000 Fax: 000-000-0000 / xxx@xxxxxxxxxxxxxxxx.xxx Serving the Parker community since 1982 Website: xxx.xxxxxxxxxxxxxxxx.xxx