Report Potential PHI Data Breach

This form is used to report potential unauthorized access, use, or disclosure of protected health information.

In accordance with Section 1.7 of Annex A of the First Amendment to the Intergovernmental Agreement between The Board of Trustees of the University of Illinois and the Illinois Department of Healthcare and Family Services (Agreement No. 2021-37-002-2), any unauthorized access, use, or disclosure of Protected Health Information (PHI) must be reported to the HFS Privacy Officer. OMI & partner end users will satisfy this reporting requirement by submitting this form.

Do NOT enter any PHI into this form or attach any documents containing PHI!

Title

A short description to explain the nature of a ticket.

Contact person for this incident:

Contact’s title:

Contact’s address:

Workplace/organization address

Contact’s e-mail:

Contact’s telephone number:

Date of Discovery:

Detailed Description:

Types of Unsecured Protected Health Information involved in the potential Unauthorized Access, Use, or Disclosure

Such as full name, SSN, Date of Birth, Address, Account Number, Disability Code, etc. - List All.

What steps are being or have been taken to investigate the potential unauthorized access, use, or disclosure; mitigate losses; and protect against any further incidents?

Number of Individuals Impacted

Other Fields

Your name

Your email address

Verification Code