Report PHI Data Breach

This form is used to report 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 notifying the Associate Director of Security Compliance of OMI 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 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 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