Incident Reporting Form

Please use this secure form for reporting HIPAA incidents. If you need assistance, please call the HIPAA Office at 501-603-1379
REPORTER INFORMATION:
Person Reporting:    
Title (If UAMS Employee):    
Department (If UAMS Employee):    
Address:    
City:    
State:    
Zip:    
Phone:    
Alternate or Mobile:    
Fax:    
E-mail:    
Date UAMS Became Aware:    
Date Incident Occurred:    
EMPLOYEE INFORMATION:
Name:    
Title:    
Department:    
Phone:    
Alternate or Mobile:    
Fax:    
E-mail:    
PATIENT INFORMATION:
Sal:    
Last Name:    
First Name:    
MI:    
DOB:    
MRN:    
Address:    
City:    
State:    
Zip:    
Phone:    
Alternate or Mobile:    
Fax:    
E-mail:    
OTHER CONTACT INFORMATION:
Contact Name:    
Other Org. (If Applicable):    
Address:    
City:    
State:    
Zip:    
Phone:    
Alternate or Mobile:    
Fax:    
E-mail:    
Contact Notes:            
Describe the incident:
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