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SFD Citizen Complaint Form

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  2. Name of person filing complaint:
  3. Ex. 123-456-7890
  4. Was the complaint in relation to (check the one that applies)?
    The Shreveport Fire Department - Emergency Mecial Services (EMS) is required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and Subtitle D of the Health Information and Technology for Economic and Clinical Health Act (HITECH) to protect the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. This statement is being provided to inform you that it may be necessary to review PHI associated with you or a family member in order to adequately address this complaint. By selected the submit button, you acknowledge that you have read and agree to the contents of this HIPPA Notice
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  7. This field is not part of the form submission.