HIPAA Incident Report Form Template
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HIPAA Incident Report Form
Please complete all fields and submit it promptly to the Privacy Officer.
Date & Time of Incident
Location of Incident
Reported By
Contact Number
Type of Incident
Unauthorized Access
Data Breach
Loss or Theft of Records
Improper Disclosure
Description of Incident
PHI Affected
Check all that apply:
Patient Name
Social Security Number
Medical Records
Insurance Information
Billing Information
Action Taken
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