Healthcare Data Breach Notification Form
Covered Entity Information
Entity Name
Contact Person
Phone Number
Email Address
Mailing Address
Individual(s) Affected
Number of Individuals Affected
Affected Individuals Information
Breach Details
Date of Breach
Date Discovered
Description of the Breach
Type of Information Involved
Check all that apply
Name
Address
Social Security Number
Date of Birth
Medical Information
Financial Information
Other
Actions Taken
Description of Actions Taken/to be Taken
Additional Information
Additional Comments/Notes