• Travis County Incident/Complaint Form

    This form is used to report incidents or complaints to Travis County regarding a HIPAA practice, policy, or procedure, or for potential privacy violations. Individuals wishing to report an incident/complaint are not required to fill out this form; they may also contact the HIPAA Compliance and Privacy Office directly.

  • **This form must be completed by the individual who discovered the incident. No third party reporting will be accepted.**

    The Health Information Portability and Accountability Act (HIPAA) of 1996, allows individuals the right to report an incident or file a complaint about our privacy policies and procedures or if you believe we have violated yours or another person’s privacy rights. When an incident/complaint is received, the HIPAA Compliance and Privacy Office will come to an appropriate resolution within 45 - 60 days. Depending on the circumstances, this may take longer. Travis County Government will not engage in any discriminatory or other retaliatory behavior against you because of an incident reported or complaint.


    Please complete as much information as possible. If you have any questions regarding this form, you may contact our HIPAA Compliance and Privacy Office (CAP) at (512) 854-1114 or email the form to privacy@traviscountytx.gov.

  • Section I

  • Would you like to remain anonymous?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you an internal staff member or an external client or vendor?*

  • Section II

  • Does this Incident/Complaint involve HIPAA Protected Health Information (PHI) or Personally Identifiable Information (PII)?

  • Section III

  • Date of Discovery
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  • Are there any Travis County devices that may need to be analyzed or suspended?
  • Is this an internal issue?
  • Have you contacted the Help Desk?
  • Current Date
     - -
  • Should be Empty: