Breach of Information Form

NOTICE: This form is to be completed when PHI has been accessed, acquired, used or disclosed in an unauthorized manner (the privacy or security of PHI has been compromised).

Associate First Name

Associate Last Name

Associate Address

City

State

Zip

Email Address

Phone Number

Alternate Phone Number

Month of Breach

Day of Breach

Year of Breach

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 and/or Policy Number
Other

Describe the incident (ie: stolen laptop, lost blackberry, car broken into, missing briefcase, misrouted patient information, etc) and include dates/times if applicable:

Describe any steps taken to mitigate damage (ie: police report, retrieved files/information unopened by the other party) and include dates/times if applicable:

Estimate the number of customers potentially affected (choose one):1-10
11-25
25-100
101-300
301-500
Over 500

Do you have knowledge of the patient names affected?

Additional Comments

MSA | Medical Services of America