Privacy Officer's Roundtable

breach investigation form

  • 1.  breach investigation form

    Posted 01-24-2020 01:20 PM
    I am curious if anyone has a template or have found it useful to have a template for an employee, manager, etc. to fill out when they experience a potential HIPAA breach? I have an investigation form that I document the incidents on but was looking at an incident form for employees to fill out. Currently they call or send me an e-mail of what happened and it is dialogue back and forth with questions I may have. If you have this would you mind sharing?

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    Savannah Knuettel
    Compliance Officer
    Galen Medical Group
    Hixson,TN

    The views expressed herein are my own and do not represent those of my employer or clients. They are not meant to constitute legal advice or create an attorney-client relationship.
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    2020 SCCE Membership


  • 2.  RE: breach investigation form

    Posted 01-24-2020 01:26 PM
      |   view attached
    Savannah,
    This is our form that staff access when they have a suspected privacy or security incident to report.

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    David Rothery, CHC
    Compliance Officer
    Marin County, CA


    These are my personal opinions and not those of the County of Marin
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    2020 SCCE Membership


  • 3.  RE: breach investigation form

    Posted 01-27-2020 11:28 AM
      |   view attached
    Here's our form that we've created although I haven't enforced its use yet - usually staff email or call me when an incident arises. This form captures a lot of the information though that would cut down on the back and forth of information gathering.

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    Aurae Beidler
    Compliance/ Privacy Officer
    Linn County Health Services
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    Attachment(s)

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  • 4.  RE: breach investigation form

    Posted 01-27-2020 11:48 AM
    Thanks David and Aurae. The form we use is proprietary and I am not permitted to share it. But the forms you attached are good examples of something I could put together to make the process easier. Right now the person calls me and I fill out the form. It would be nice to have an initial sheet they fill in and some basic instructions for mitigation before they get me involved.

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    Carl Russell
    Compliance Analyst, CHPC
    Delta Dental of Idaho
    Boise,ID

    Anything I say is my sole opinion and not of my company.
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    2020 SCCE Membership


  • 5.  RE: breach investigation form

    Posted 01-27-2020 02:17 PM
    Thanks, David and Aurae!

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    Marie Wagner, CHC, CHRC
    Operations Manager, Corporate Compliance
    The Queen's Health Systems
    Honolulu, HI
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    2020 SCCE Membership


  • 6.  RE: breach investigation form

    Posted 01-27-2020 02:18 PM
    Thank you everyone this is very helpful!!

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    Savannah Knuettel
    Compliance Officer
    Galen Medical Group
    Hixson,TN

    The views expressed herein are my own and do not represent those of my employer or clients. They are not meant to constitute legal advice or create an attorney-client relationship.
    ------------------------------

    2020 SCCE Membership