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.

Type of Incident*

Select

Method of Identification*

Select or enter value

Information Error Individual*

Select or enter value

Unauthorized Recipient(s) of Protected Information*

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Person Completing Form*

Please include first and last name.

Manager Name*

Please include the first and last name of your direct manager.

Who initially reported the Incident?*

Please include full name of individual or entity.

Date of Incident*

If known.

Date of Discovery of Incident*

If known.

Description of Potential Incident*

Triage Ticket #*

Include Jesica Groff on triage ticket.

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

Affected Member/Group Name

(Name, Full Address, Member ID)

Affected Member Beam ID # or Group #*

Location of Incident*

Select

Type of Information Involved*

Select

Steps Taken to Mitigate Incident*

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

Incident Description

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