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PHI Privacy Incident Form
Name
First
Last
Contact
Email
Phone
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Date of incident
Format of PHI that was compromised
Paper
Electronic
Type of PHI that was compromised. Check all that apply.
Social Security Number
Name, address or date of birth
DIagnosis information
Physicians medical records/orders/CMNs
Health insurance info (carrier name/policy number)
Other…
Enter other…
Describe the Incident
Example: stolen laptop, lost blackberry, car broken into, missing briefcase, misrouted patient information, etc) and include dates/times if applicable
Estimate the number of customers potentially affected
1-10
11-25
25-100
100-300
301-500
Over 500
Do you have knowledge of the patient names affected?
Yes
No
Additional comments
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