Report a new Privacy Incident

New Privacy Incident

FIRST: Please contact Jonathan Steffer, of USF Clinical Affairs, at 813-974-6738 or you may send an email request to steffer@usf.edu to have a courier dispatched to pick up and return the disclosed document(s) to USF Health.
SECOND: Please complete the form below to report this privacy incident. If you have any questions, do not hesitate to contact the Privacy & Healthcare Civil Rights Compliance Department at (813) 974-2222 or via email at Privacy@usf.edu.
THANK YOU for reporting this incident. If we have any questions regarding your submission, we will reach out to you.

Basic Information

Privacy & Healthcare Civil Rights Compliance will assign label

Date We Learned of Mistake *

Date Mistake Occurred

Physical Location / Clinical Department *

Patient

Name *

MRN *

DOB *

Phone *

Remove Patient

Add Another Patient

Detailed Information

Specific PHI Compromised *

PHI Disclosed To *

Tell us how this mistake occurred. Attach at copy of document released. *

Was a courier contacted to pick up PHI?

Was the original document returned to USF Health?

If original was not returned, indicate whether it was shredded or destroyed?

Please explain what happened to the PHI?

Name *

Phone *

Title / Dept *

Email *

New Privacy Incident

Basic Information

Patient

Detailed Information

Please Identify Yourself