Better Business Bureau of Wisconsin, Inc. Complaint …
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Better Business Bureau of Wisconsin, Inc. Complaint Authorization and (HIPAA) Privacy Release Form
Complainant Name: _____________________________________Date: ____________________
Home Address: __________________________________________________________________
City: ______________________________ State ______________ Zip:______________________
Home Phone: __________________________________________
Work Phone: ___________________________________________
Email Address: _________________________________________
Fax: __________________________________________________
BBB Case #: ___________________________________________
I hereby request and authorize Wisconsin Better Business Bureau and any BBB staff member, to make an inquiry on my behalf addressing this matter. I further authorize the disclosure of any information governed by HIPAA that may to address the complaint issues. I further understand that I will hold harmless any agencies divulging information pursuant to this release of information, as well as the Better Business Bureau of Wisconsin, Inc. and any of its affiliates and employees in these matters.
Printed Name: _________________________________________ Date: ____________________
Signature: ____________________________________________
PLEASE SIGN AND RETURN TO: BBB of Wisconsin, Inc.
Attn: Complaint Department 10101 W. Greenfield Ave., Ste 125
Milwaukee, WI, 53214
I hearby authorize the Better Business Bureau of Wisconsin, Inc. to ,make an inquiry on my behalf within an effort to address the issue(s) with
Name of Company/Agency: _______________________________________________
Signature: _______________________________________________Date: __________________
Better Business Bureau of Wisconsin, Inc. / wisconsin. / email: info@wisconsin. 10101 W. Greenfield Avenue, Suite 125 ? Milwaukee, WI 53214 Phone: (414) 847-6000 ? Fax: 414-302-0355
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