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university health center Complaints and Appeals Form
Please complete the following form in its entirety and press “submit" to process your complaint.

 

Last Name: First Name: MI:

Local Address:

Telephone Number: Email Address:

Student ID Number (810 Number):

This form and website are not a secure method of communication. This form will be sent to officials at the University Health Center and University of Georgia. To protect your privacy do not include any medical, psychological, or psychiatric details of your condition or visit to the University Health Center. The Health Insurance Portability and Accountability Act (HIPAA), the University Health Center, and the University of Georgia strive to guard your Protected Health Information (PHI). Protected health information includes any individually identifiable health information that is explicitly linked to you or could allow individual identification.

Please describe the nature of your complaint including any prior action taken to date: