Medical Records Disclosure Incident Report Form
Use this form to report suspected or confirmed disclosure, access, loss, or transmission of medical records, and provide the details needed to review the incident.
Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Job Title or Role
*
Department or Organization
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reporter Type
*
Affected patient
Staff member
Other authorized reporter
Incident Details
Date and Time of Disclosure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time Discovered
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Disclosure Type
*
Please Select
Unauthorized viewing
Verbal disclosure
Emailed to wrong recipient
Faxed to wrong number
Lost paper records
Misplaced device
System access issue
Other
Record Type Involved
*
Please Select
Medical records
Billing records
Lab results
Imaging records
Prescription records
Mental health records
Substance use treatment records
Other
How Were the Records Disclosed?
*
Please Select
In person
By phone
By email
By fax
Through mailed documents
Through electronic system access
By physical loss or misplacement
Other
Is the Incident Ongoing?
*
Yes
No
Unknown
Detailed Narrative Description
*
People and Records Involved
Department or Team Involved
*
Please Select
Front Desk
Nursing
Billing
Medical Records
Radiology
Laboratory
Provider Office
IT
Other
Person Who May Have Disclosed the Records (Name or Role)
Recipient Name, Role, or Relationship
Number of Records or Patient Files Affected
*
Types of Records Affected
*
Images
Lab Results
Visit Notes
Billing Information
Medication List
Demographics
Referral Information
Other
Immediate Response and Evidence
Immediate action taken after discovery
*
Access revoked
Records recovered
Device secured
Area secured
Individual notified
Other
Who was notified
*
Supervisor
Privacy/Compliance personnel
Information Security
Management
Other
Additional evidence or attachments available?
*
Yes
No
Supporting evidence files
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