Report a new Privacy Incident

New Privacy Incident

Please use this form to report a potential wrongful use or disclosure of patient information. Fill in as many of the fields below as possible. This form will be sent to your organization's patient privacy department for review and follow-up.

"PHI" stands for Protected Health Information, which in general is any demographic, clinical or financial information that is identifiable to a specific person.

For immediate assistance please contact the Corporate Privacy Office at (866) 898-8891 or (910) 715-2434

Basic Information

Discovery Date *

Occurrence Date

Facility *

Department

Location

Patient

Name *

MRN

Acct #

DOB *

Phone

Remove Patient

Add Another Patient

Detailed Information

Specific PHI Compromised *

PHI Disclosed To *

Description *

If appropriate, attach a screen shot, photo, report, or other document to further describe this incident.

Attachment

Name *

Phone *

Title / Dept *

Email *

New Privacy Incident

Basic Information

Patient

Detailed Information

Please Identify Yourself Anonymous

Please Identify Yourself
Anonymous