HIPAA/DATA Incident Report



HIPAA/DATA INCIDENT REPORTMichigan Department of Health and Human ServicesToday’s DateDate of IncidentTime of Incident (if applicable)Date Incident Discovered FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contact InformationYour NameMDHHS Division/Section FORMTEXT ????? FORMTEXT ?????Your Phone NumberYour Email FORMTEXT ????? FORMTEXT ?????Your LocationYour Supervisor FORMTEXT ????? FORMTEXT ?????Incident InformationLocation of Incident (if applicable)Incident Type FORMTEXT ????? FORMDROPDOWN If “Other” is chosen in “Incident Type,” explain below FORMTEXT ?????In what medium was the information disclosed? FORMDROPDOWN If Other, explain below FORMTEXT ?????Police Report Number and Agency (if applicable) FORMTEXT ?????Is your office a HIPAA-covered entity?Was the information encrypted and password protected? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX OtherIf Other, explain below FORMTEXT ?????Item/Equipment Involved FORMDROPDOWN If Other, explain below FORMTEXT ?????Describe what happened FORMTEXT ?????Did a vendor or other entity outside of MDHHS disclose the information?If yes, is there any sort of agreement with the other entity? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX N/AThe number of people whose information was disclosedHow many people in total does your program serve? FORMTEXT ????? FORMTEXT ?????Nature and Extent of Information InvolvedFinancial Information(check all that apply)Health Information(check all that apply)Clinical Information(check all that apply) FORMCHECKBOX Credit Cards FORMCHECKBOX STDs/STIs FORMCHECKBOX Treatment Plan FORMCHECKBOX Social Security Numbers FORMCHECKBOX Mental Health Information FORMCHECKBOX Diagnoses FORMCHECKBOX Account Numbers FORMCHECKBOX HIV/AIDS FORMCHECKBOX MedicationDescribe: FORMTEXT ????? FORMCHECKBOX Substance Abuse FORMCHECKBOX Medical History FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Test Results FORMCHECKBOX Other: FORMTEXT ?????What Identifiers are Involved (check all that apply) FORMCHECKBOX Names FORMCHECKBOX Medicaid Recipient Numbers FORMCHECKBOX Internet Protocol (IP) Address Number FORMCHECKBOX Addresses FORMCHECKBOX Health Plan Beneficiary Numbers FORMCHECKBOX Finger or Voice Prints FORMCHECKBOX Dates FORMCHECKBOX Certificate/License Numbers FORMCHECKBOX Any other Unique Number,Characteristic, or Code that mayidentify an individualDescribe: FORMTEXT ????? FORMCHECKBOX Account Numbers FORMCHECKBOX Telephone Numbers FORMCHECKBOX Web Universal Resource Locator (URL) FORMCHECKBOX Any Vehicle or Other DeviceSerial Numbers FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Fax Numbers FORMCHECKBOX Social Security Numbers FORMCHECKBOX Email Addresses FORMCHECKBOX Medical Record Numbers Has the information that was used or disclosed been reviewed by the Institutional Review Board (IRB)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX N/AWhat security policies/procedures are involved? FORMTEXT ?????Were those policies/procedures followed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AHave you attempted to retrieve the information? FORMCHECKBOX No FORMCHECKBOX Yes – If Yes, explain. FORMTEXT ?????Additional comments FORMTEXT ?????Save document and email to:MDHHSPrivacySecurity@ ................
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