Reporting a HIPAA Violation

 Step 1 of 1

All personnel must report all known and suspected breaches of unsecured PHI and all security incidents immediately to the HIPAA Compliance Officer. If an incident occurs, or is suspected to have occurred, the staff member with knowledge of the incident must complete this form to the best of his/her knowledge and provide as much detail about the incident as possible

* Denotes a required field
Date of Report*
Date of Discovery of Breach*
When describing the breach please include date, time, patients affected, parties involved, whether any hardware or devices were involved, and any other information.