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Miami County Board of Developmental Disabilities HIPAA Breach Reporting

1.Date and Time of the Potential Breach
Date / Time
Time
:
2.Description of the Breach: Please provide a brief description of what happened, including the individuals served name.
3.Type of Protected Health Information (PHI) Involved: List what specific data elements were exposed (e.g., Social Security numbers, medical record numbers, names, dates of birth, diagnostic information)
4.Disclosure Identification: List who the unauthorized person who used the protected health information was or to whom the disclosure was made.
5.Extent of Breach/Disclosure: Provide information on if the protected health information was actually acquired or viewed.
6.Investigation and Mitigation: List what steps have you taken to investigate the breach, mitigate harm to affected individuals, and protect against further breaches.
7.Add your name and contact information if you would like contacted about this possible breach.