HIPAA BREACH REPORT FORM PERSONAL AND CONFIDENTIALDate Breach Reported:* MM slash DD slash YYYY (Date of Discovery)Date Breach Occurred:* MM slash DD slash YYYY (PHI accessed/transmitted/Disclosed) to unauthorized individual)SECTION 1: Information for Person Reporting BreachName of person reporting Breach:* First Last Phone Number:*Section 2: Personal Health Information That Was Accessed or DisclosedNumber of patients impacted:** Select All Name Address Phone Number Gender Date of Birth SSN Member Plan ID# Medicare# Medicaid# Other Insurance Information Diagnosis Code/Information Plan Name Procedure Code/Treatment Received Name of Providers Dates of Treatment/Service Other:_________________________________________________________________________ Section 3: Method of Breached PHISource of breached PHI:* Select All Ransomware Network breach (hacking incident) Stolen Cell Phone Stolen Desktop Computer Stolen Laptop Stolen Tablet E-mail Phone Public Conversation Fax Copier Mail SFTP/FTP Site Section 4: Format of PHI Disclosed* Select All Claim Form Explanation of Benefit Authorizations Letter Member ID Card Case Management /Disease Management Member Letter Provider Termination Letter to Member Claim Letter New Member Mailing E-mail Dis enrollment/Reinstatement/Member Letter Enrollment Verification Letter Others: ___________________________________________________ What is the present location of the breached information?*Who has viewed the information?*Who has viewed the information?* Select All Trashcan (Intact as received) Trashcan (Shredded into pieces) Section 6: Information on Person Completing This FormName:*Title:*Phone Number:*Signature:Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
