Report a new Privacy Event

New Privacy Event

Please complete the form below and press the Submit button at the bottom. Explanations of the various fields can be found by clicking on the '?" icon.

If you have any questions, contact the Privacy and Security office at 1-580-272-2706 or email us at privacyandsecurity@chickasaw.net.

Basic Information

When was this Incident Discovered *

When did this incident Occur? (give range if appropriate)

Physical Location/Clinical Department

Department

Describe Specific Location

Identify Patient, if not known type "unknown"

Name *

MRN

DOB

Phone

Remove Patient

Add Another Patient

Request Description

Describe Disclosed PHI *

Who Was the PHI Disclosed To or "unknown" *

Please Describe Incident *

Name *

Phone *

Title / Dept *

Email *

New Privacy Event

Basic Information

Identify Patient, if not known type "unknown"

Request Description

Please Identify Yourself Anonymous

Please Identify Yourself
Anonymous