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Name of person completing form

Name of affected member (optional)

Member ID of affected member (optional)

Email of person completing form

Date incident occurred

Date incident was detected

Where did this breach occur? Where did this breach occur? *Business AssociateMotivHealthOther

Brief summary of incident, including number of customers affected

Was protected health information (PHI) involved? Was protected health information (PHI) involved? Yes No Includes all individually identifiable health information, including demographic data, medical histories, test results, insurance information, and other information used to identify a patient or provide healthcare services or healthcare coverage. ‘Protected’ means the information is protected under the HIPAA Privacy Rule.

Was the PHI unsecure? Was the PHI unsecure? Yes No

Was there a disclosure, access, or use of PHI in a way that is not permitted by the Privacy Rule? Was there a disclosure, access, or use of PHI in a way that is not permitted by the Privacy Rule? Yes No

Does an exception apply? There are three exceptions to the definition of “breach.” Does an exception apply? There are three exceptions to the definition of “breach.” Yes No

How many individuals were affected by the breach? How many individuals were affected by the breach? More than 500 Less than 500 NA

Based on the factors above, is there a low probability that the PHI has been compromised? Based on the factors above, is there a low probability that the PHI has been compromised? Yes, there is a low probability and no breach reporting is required under HIPAA No, there is a high probability that PHI was compromised and breach reporting is required

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Date