U.S. Department of Health and Human Services
Office for Civil Rights

Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information

Breach Tracking Number:

Thank you for filing a breach notification via the website of the Office for Civil Rights (OCR) at the Department of Health and Human Services. This is an automated response to acknowledge receipt of your breach notification.

Please do not fax, email, or mail a copy of this breach notification to us as that may delay the processing of your breach notification.

If you have questions or would like to provide feedback about the Health Insurance Portability and Accountability Act (HIPAA) Breach Notification process, or OCR's investigative process, please send us an email at OCRbreachreportingfeedback@hhs.gov.

* Breach Affecting:
* Report Type:

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Covered Entity
* Name of Covered Entity:
* Type of Covered Entity:
* Street Address Line 1:
Street Address Line 2:
* City:
* State:
* ZIP:

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Covered Entity Point of Contact Information
* First Name:		* Last Name:
* Email:

* Phone Number: (Include area code):

Contact Phones Phone Number Usage

* Breach Start Date:		* Breach End Date:
* Discovery Start Date:		* Discovery End Date:

* Approximate Number of Individuals Affected by the Breach:

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* Type of Breach:
* Location of Breach:
* Type of Protected Health Information Involved in Breach:
* Brief Description of the Breach:
* Safeguards in Place Prior to Breach:

* Individual Notice Provided Start Date:		Individual Notice Provided Projected/Expected End Date:
Was Substitute Notice Required?
Was Media Notice Required?

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* Actions Taken in Response to Breach:

Under the Freedom of Information Act (5 U.S.C. §552) and HHS regulations at 45 C.F.R. Part 5, OCR may be required to release information provided in your breach notification. For breaches affecting more than 500 individuals, some of the information provided on this form will be made publicly available by posting on the HHS web site pursuant to § 13402(e)(4) of the Health Information Technology for Economic and Clinical Health (HITECH) Act (Pub. L. 111-5). Additionally, OCR will use this information, pursuant to § 13402(i) of the HITECH Act, to provide an annual report to Congress regarding the number and nature of breaches that are reported each year and the actions taken to respond to such breaches. OCR will make every effort, as permitted by law, to protect information that identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy.

I attest, to the best of my knowledge, that the above information is accurate.

* Name:

Date: 05/19/2024