HIPAA Incident Report

What is a HIPAA violation?

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.

What is a HIPAA breach?

A HIPAA breach is any HIPAA violation that involves technology, including computers tablets, cell phones, laptops, or email.

Whether big or small, all suspected HIPAA violations should be reported.

Please use this form to report any violation or breach of confidential patient or client information or data.

Your report is completely anonymous unless you tell us your name and contact information at the end of this form.


About the Violation or Breach

Type of SECURITY Violation*

Type of PRIVACY Violation*

Please describe a type of violation not listed above. Be as descriptive as you can.


Location of or How Information was Compromised

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.

Drag and drop files here or

What happens now?

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 more information

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


About You

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.