HIPAA Reporting Form

On-line Submission – Best Used With: Edge, Chrome, Firefox, or Safari


 

Name (if comfortable)
Are you...
other
When did this occur?
Person(s) Involved
What kind of incident is this?
Allegation
Description of the incident
Would you be willing to discuss the above allegations with the Privacy Officer?*
How do we best get in touch with you?
How did you come to learn of the incident?
Have your discussed the allegation with anyone else?
Who did you speak to about the allegation?
Other Information
Do you have any further information to provide or any suggestions for verifying the allegations?
Verification:
Are you aware of any other individuals who may be able to provide further information regarding the allegation?
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