COUNTY OF LOS ANGELES
COUNTY OF LOS ANGELES
DEPARTMENT OF AUDITOR-CONTROLLER
HIPAA Compliance Unit
500 WEST TEMPLE STREET
SUITE 410
LOS ANGELES, CA 90012
PHONE: (213) 974-2164
J. TYLER McCAULEY
AUDITOR-CONTROLLER
PRIVACY INCIDENT REPORT
FOREWARD
• The Health Insurance Portability and Accountability Act of 1996 provide protections against the unauthorized disclosure of protected health information (PHI) in either paper or electronic based mediums.
• Patients have a legal right to review and submit an amendment/correction on most aspects of PHI from their health care provider (Medical Record).
• PHI used for purposes of treatment or billing does not require authorization.
• County workforce or the public may report suspected privacy incidents such as unauthorized, inappropriate and accidental disclosures of a patient’s protected health information (PHI).
INSTRUCTIONS
1. The Complainant shall complete Sections I & II of this report. Attach additional sheets as needed.
2. The Complainant shall send the signed completed Privacy Incident Report to the Auditor Controller Chief Privacy Officer (CPO) via Post, Fax, or Email:
a. Post: Department of Auditor Controller – HIPAA Compliance Unit, 500 West Temple Street, Suite 410, Los Angeles, California 90012;
b. Fax: (213) 620-7096;
c. Email: HIPAA-Hotline@auditor.co.la.ca.us;
3. Upon receipt, the CPO shall review the incident to determine appropriate action.
NOTE: This is an administrative report, DO NOT include this in any agency designated record set(s), including client health records.
SECTION I – GENERAL INFORMATION
Name of Person Reporting Incident ________________________________________________________
Telephone Number ( ) - x Email Address______________________________
Department/Division, if County Employee
SECTION II – PRIVACY INCIDENT INFORMATION
Date of Incident _ Location of Incident
Description of Incident (Include the names of those involved, dates, times and places in the privacy incident. Attach additional sheets, numbered and dated, as needed).
_
Incident also reported to
Signature:_ Date:
Signature of County Chief Privacy Officer: Date Received:
Print Name of County Chief Privacy Officer:
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