HIPAA Incident Form
Do not include patient or staff names. Instead, use patient chart numbers and position titles to identify and describe.
Form Completed By:
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BSHC Location of Incident: (Clinic Name)
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Date of Form Completion:
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Month
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Day
Year
Date
Breach Start Date:
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Month
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Day
Year
Date
Breach End Date:
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Month
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Day
Year
Date
Discovery Start Date:
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Month
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Day
Year
Date
Discovery End Date:
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Month
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Day
Year
Date
Number of Individuals Affected:
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Type of Breach: (Select one or more)
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Hacking/IT Incident
Improper Disposal
Loss
Theft
Unauthorized Access/Disclosure
Location of Breach: (Select one or more)
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Desktop Computer
Electronic Medical Record
Email
Laptop
Network Server
Other Portable Electronic Device
Paper/Films
Other
Type of Protected Health Information Involved in Breach: (Select one or more)
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Clinical
Demographic
Financial
Other
If Clinical: (Select one or more)
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Diagnosis/Conditions
Lab Results
Medications
Other Treatment Information
If Demographic: (Select one or more)
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Address/Zip
Driver's License
Date of Birth
Name
SSN
Other Identifier
Brief Description of the Breach:
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Signature
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Do not include patient or staff names. Instead, use patient chart numbers and position titles to identify and describe.
Submit
Should be Empty: