/ CLIENT COMPLAINT /
PHIPA COMPLAINT
SUMMARY FORM
PHI – 521 Form
Client Complaint / PHIPA Complaint Summary Form / Page 1 of 2 / December 8, 2008, Rev July 17, 2013
/ CLIENT COMPLAINT /
PHIPA COMPLAINT
SUMMARY FORM
PHI – 521 Form
CLICK HERE for French version of PHI-521 Form
Policy References CS-0030 Complaints from Clients and PHI-EE-550 Client Complaint Process
Client Complaint / PHIPA Complaint Summary Form / Page 1 of 2 / December 8, 2008, Rev July 17, 2013
/ CLIENT COMPLAINT /
PHIPA COMPLAINT
SUMMARY FORM
PHI – 521 Form
NAME OF PROGRAM/SERVICE
LOCATION / SSM / Central Algoma / East Algoma / North Algoma
FILE ALERT / Yes / Details: / Not Applicable
CLIENT NAME
/
FILE #
GENDER
/ Male / Female /
D.O.B.
/
AGE
(mm/dd/yyyy)
I,
Print full name / Date of Birth
(mm/dd/yyyy)
of,
Print full address
Wish to formally complain to the: / Executive Director
Privacy Specialist / of
Agency name
in regards to:
AFS Services
Access to Personal Health Information (PHI)
Disclosure of Personal Health Information (PHI)
Correction of Personal Health Information (PHI)
Other Management of Personal Health Information (PHI) / For complaints regarding PHI
  • I understand that I will receive a response from the Privacy Specialist within 30 days.
  • I also understand that I may forward my complaint at any time directly to:
Office of the Information and Privacy Commissioner of Ontario
2 Bloor Street East, Suite 1400
Toronto, ONM4W 1A8
Telephone (416) 326-3333
Toll Free 1-800-387-0073
Fax (416) 325-9195
Client’s complaint (in his/her own words):
Client Complaint / PHIPA Complaint Summary Form / Page 1 of 2 / December 8, 2008, Rev July 17, 2013
/ CLIENT COMPLAINT /
PHIPA COMPLAINT
SUMMARY FORM
PHI – 521 Form
Staff involved and role with the Client:
Actions taken / Corrective measures taken:
Client satisfaction regarding the actions taken and corrective measures:
List implications for future and suggestions for policies or practice changes:
SIGNATURES
Client Name
(Print) / Signature / Date
(mm/dd/yyyy) / Not Applicable
AFS Clinician Name
(Print) / Signature / Date
(mm/dd/yyyy) / Not Applicable
AFS Manager Name
(Print) / Signature / Date
(mm/dd/yyyy) / Not Applicable
FORM DISTRIBUTION RECORD
Please attach any relevant case notes, correspondence, relevant additional material, etc. / Not Applicable
Date
(mm/dd/yyyy) / Initial
Copy to Executive Director / Not Applicable
Date
(mm/dd/yyyy) / Initial
Copy to AFS Privacy Officer (for PHI Complaints only) / Not Applicable
Date
(mm/dd/yyyy) / Initial
Client Complaint / PHIPA Complaint Summary Form / Page 1 of 2 / December 8, 2008, Rev July 17, 2013