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