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Report an Incident

Please complete the form below as completely as possible

Date of Incident

Date Discovered

Reported By

Reporter Phone Number

Reporter Email

Type of Incident

Unauthorized Access

Unauthorized Use/Disclosure

Violation Of Policy

Malicious Software

Denial Of Service

Unplanned Downtime

Theft

Other

Description of the incident

How was the incident discovered

Personal and/or Health related information involved?

Number of individuals potentially affected

Types of information involved (Check all that apply)

Social Security Number

Date of Birth

Demographic (Full/Partial Name)

Insurance Member ID

Account Numbers

Insurance Claim Numbers

Home Address

Codes or any reference to diagnosis or treatment

Other

If other, please explain

Exception Type

Exception Message

Stack Trace

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