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About
Join Us
Wellness
Behavioral Health
Learning Differences
Communities
Youth
Women
Asian
Black
Solutions
MyCuraJOY
Youth Ambassadors
For Healthcare
For Education
Behavior Therapy
Blog
❤ Donate
Incident Reporting Forms
HIPAA Violation Reporting Form
Person Reporting Incident
*
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I am reporting a
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Unauthorized Access
Improper Disposal of PHI
Data Breach or Leak
Unauthorized Disclosure
Other
Other
Date / Time of Incident
*
Date
Time
*
Time
Location of Incident
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Please describe the event in detail.
*
How Did You Beware of this Incident
*
Additional Comments:
Preferred Follow-Up Method
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Email
Text
Phone
Email
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Number
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Submission
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I would like to remain anonymous
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If you are human, leave this field blank.
