Fillable PRIVACY INCIDENT REPORTING FORM (Department of Health Care Services)

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PRIVACY INCIDENT REPORTING FORM (Department of Health Care Services)

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PRIVACY INCIDENT REPORTING FORM
The information reported in this form will be strictly confidential and will be used in part
to determine whether a breach has occurred. Do not include specific PHI or PI in this
form.
1- CASE IDENTIFYING INFORMATION
DHCS privacy case number:
Reporting entity:
DHCS internal Health plan County Other (specify):
Reporting entity’s privacy incident case number:
Contact name:
Contact email:
Contact telephone number:
2- SUMMARY OF PRIVACY INCIDENT
Return completed form to: privacyofficer@dhcs.ca.gov
Page 2
3 - BREAKDOWN OF SUMMARY
Date(s) of privacy incident: Date of discovery:
Date reported to DHCS:
Number of DHCS/CDSS program beneficiaries impacted; please specify which program(s)
they belong to:
How many of the impacted beneficiaries are minors:
Title of person who caused the incident:
Title of unintended recipient:
Suspected malicious intent: Yes No
4 – DATA ELEMENTS
Demographic Information (check all that apply)
First name or initials Last name Address/ZIP
Date of birth CIN or Medi-Cal # Social security number
Driver’s license Membership # Health plan name
Mother’s maiden name Image Password
User name/email address
Program name:
Other:
Financial Information (check all that apply)
Credit card/bank acct # EBT card PIN #
Claims information EBT card #
Other:
Clinical Information (check all that apply)
Diagnosis/condition Diagnosis codes Procedure codes (CPT)
Medications Lab results Provider demographics
TAR # Psychotherapy notes Mental health data
Substance use/alcohol data
Other:
Please list all data elements provided by DHCS:
Please list all data elements verified by SSA:
Return completed form to: privacyofficer@dhcs.ca.gov
Page 3
5 - LOCATION OF DISCLOSED DATA
Laptop Network server Desktop computer
Portable electronic device Email Electronic record
Paper data Smart phone Hard drive
CD/DVD USB thumb drive Fax
Social media Other:
6 – SAFEGUARDS/MITIGATIONS/ACTIONS TAKEN IN RESPONSE TO EVENT
Was involved staff trained in HIPAA privacy/security within the past year: Yes No
Was malicious code or malware involved: Yes No N/A
Was the data encrypted per NIST standards: Yes No N/A
Status of the data (recovered, destroyed, etc.):
Was an attestation of nondisclosure/destruction obtained: Yes No
(NOTE: If a written attestation is not attached it will be considered verbal)
Was a police report filed: Yes No
Police report # and department name:
MITIGATION SUMMARY (Immediate actions taken to prevent further unauthorized
disclosure of data)
Return completed form to: privacyofficer@dhcs.ca.gov
Page 4
7 - CORRECTIVE ACTION PLAN (CAP) - Please include implementation date
(A CAP is implemented in an attempt to prevent this type of privacy incident from reoccurring).
8 - DETERMINATION
Has your entity determined this to be a (check all that apply):
Federal breach State breach Non-breach
In the event DHCS determines a notification is not legally required, do you still intend
to send written notification: Yes No
(Review & approval by DHCS is still required prior to dissemination of all notification
letters)
An incident is presumed to be a breach. If you have evidence under 45 CFR
164.402(2)(1)(I-IV), please provide the evidence and the HIPAA provision that applies
to find that a breach does not exist.
HITECH BREACH DEFINITION AND EXCEPTIONS
Return completed form to: privacyofficer@dhcs.ca.gov
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Completed 7 February 2021

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