HIPAA Incident Report
A HIPAA violation is any disclosure of Protected Health Information, whether intentional or unintentional, to anyone who is not authorized to have or see it. It can be technical or on paper, seen or overheard.
A HIPAA breach is any HIPAA violation that involves technology, including computers tablets, cell phones, laptops, or email.
Your report is completely anonymous unless you tell us your name and contact information at the end of this form.
Please describe a type of violation not listed above. Be as descriptive as you can.
By "location", we mean the place where the information was when it was compromised.
What information do you think, know or suspect was compromised? Please be as comprehensive as possible.
If known, please list client name(s).
Approximate number of individuals affected (if you know).
Approximate date violation occurred (if you know).
When did you first suspect there was a violation?
Are there any other details or information that you can add?
Click on Upload..., locate the file, document or snip you want to add, and follow the screen prompts.
Family Service League investigates every report of a breach or suspected breach. If a breach is determined to have occurred, there are specific steps FSL will take, depending on the PHI disclosed and the number of individuals affected, and as directed by federal law.
For a copy of FSL's HIPAA or Compliance policies and procedures,or if you prefer to share your concerns by phone, please call the: HIPAA Hotline: 631-907-2067
This section is completely optional. If you would like us to contact you, please complete this section.
By doing so, you consent to FSL contacting you, using any of the contact methods you provided below.
Otherwise leave this section blank.