Report of Potential HIPAA or other Data/Privacy Incident

This form is to be used by the business to report any potential HIPAA or other Data/Privacy incidents so that the reported incident(s) can be investigated and undergo a risk analysis.

 
 
 
 
 

Please include full name of individual or entity.

 

If known.

 

If known.

 
 
 

Include Jesica Groff on triage ticket.

If no triage ticket required, add "N/A"

 
 
 

Please describe the steps that were immediately taken to mitigate the HIPAA and/or data incident.