HIPAA
Reporting Form

Name (optional)
Are you...
If other...
When did this occur?
Kind of Incident
Person(s) involved

Allegations

Description of the Incident
Would you be willing to discuss the above allegations with the Privacy Officer?
How can we get in touch with you?
How did you come to learn of the incident?
Have your discussed the allegation with anyone else?
If so, then who?

Other Information

Do you have any further information to provide or any suggestions for verifying the allegations?
Are you aware of any other individuals who may be able to provide further information regarding the allegation?

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