CMS and SSA should protect the identity of individuals filing complaints of discrimination and of instructions against which charges are made. Should an individual be reluctant to reveal histhe individual's identity, accept an anonymous complaint. DO’s should keep in mind that disclosure of identity of a person filing a charge of discrimination could result in the individual's economic or even personal harm. Similarly, the reputation of a provider could be unjustly impaired by disclosure that a complaint had been filed against it.

The following basic information should be obtained and recorded on an SSA-5002, Report of Contact:

1. 1. 

   The name and address of the facility where the incident occurred;

2. 2. 

   The date the incident occurred;

3. 3. 

   The basis for the complaint (race, color, or national origin);

4. 4. 

   The services or facilities about which the complaint is being made (admissions, bed assignment, dual standards for the cost of medical service, dual standards in assignments to or use of hospital facilities, visiting privileges, etc.) including a complete narrative description concerning the nature of the practices alleged to be discriminatory. When possible, names and titles of persons involved should be given.

5. 5. 

   The name, address, and telephone number, if any, of the complainant. This information may be needed to contact the person for more information and to notify the person of the results of the investigation. If the complainant appears to be reluctant to identify himself explain that the information will be kept confidential and will not be released to anyone without the complainant consent. If the individual refuses to give this information, accept the complaint and indicate that the complainant prefers to remain anonymous.

6. 6. 

   If a complaint has been made to the provider or the State health or welfare department, indicate to whom the complaint was made, the date, and the outcome if known.

A single copy of the complaint should be routed directly to the Regional Director for OCR, DHHS, who has jurisdiction for the region in which the provider is located.

The envelope should bear the legend “Confidential-Administrative Mail.” and be addressed to the “Regional OCR Director, Department of Health and Human Services,” at the addresses shown below:

When an individual files a complaint, the individual should be informed that it will be forwarded to OCR which will acknowledge receipt and after investigation, notify the individual of the outcome. The processing time of such complaints varies, so advise the individual that further contacts regarding the matter should be made with OCR at the address shown in HI 00208.060C.