Completing The Breach Determination Assessment Form

The Department of Health and Human Services Office for Civil Rights requires Organizations to report Breaches affecting protected health information. Before completing the Breach Determination Assessment Form, please refer to the Job Aid for Analysis of Security of PHI to determine whether or not the incident involved unsecured PHI.

Once you have completed the Breach Determination Assessment Form, please save it to your computer. The Breach Determination Assessment Form will need to be uploaded as evidence upon submitting a new incident to the Guard Incident Manager. This Form will not be sent to the HHS, but is used to better determine if an Incident is, in fact, a Breach, for your records.

Once the Breach Determination Form is filled out, please contact [email protected] to schedule some time to discuss the Incident with our Audit Response Team.

You can download the Breach Determination Assessment Form below.