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This form is for individuals to report HIPAA incidents and concerns involving clinical care or services provided by University affiliated clinicians and staff (including Yale Medicine, Yale Health, Yale School of Nursing etc) to the HIPAA Privacy Office so that we can track and respond to events that may involve inappropriate use or disclosure of PHI through mitigation, increased training, and/or investigation where necessary. Reports are confidential and individuals who report concerns related to HIPAA compliance in good faith may not be subject to retaliation or harassment as a result of raising the concern.
Name (not required but it will allow us to follow up with any additional questions):
e-mail address or phone (not required but will allow us to follow up with any additional questions):
Date of incident:
Location of incident:
Name of employee(s) involved:
Name of patient(s) involved, if known. Where possible include MRN or other second identifier:
Brief description of the event and any corrective actions taken such as retrieving misdirected documents or correcting charting errors:
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