Privacy and Security Complaint Form

Privacy and Security Complaint Form

This form is used to report concerns or incidents related to privacy, confidentiality, or information security involving Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA)and applicable state and federal laws. All complaints will be handled confidentially to the extent possible.
Complainant Information
You may submit this form anonymously. Providing contact information may help with follow-up.
Name

First NameLast Name
Job Title
Department
Phone Number
Please enter a valid phone number.
Incident Information
Date of Incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Location (facility, unit, system, or device)
Type of Complaint (check all that apply)

Unauthorized access to PHIImproper use or disclosure of PHIRecords leftunsecured or visible to unauthorized individualsPassword sharingor login security concernHacking, phishing, ransomware, or malware incidentOther HIPAA-related concerns (please specify)
Information Involved (check all that apply)

Protected Health Information (PHIResident demographic informationClinical records (diagnoses, medications, lab results, care notes)Billing or insurance informationElectronic Health Record (EHR)Paper recordsEmail, text, message, or voicemailOther
Description of Incident
Please describe what happened. Include names, systems, record types, and any actions taken if known.
Should be Empty: