Contact’s Email: Contact’s Telephone No: Business Associate hereby notifies FHKC that there has been a Breach of Unsecured (unencrypted) Protected Health Information that Business Associate has used or has had access to under the terms of the Business Associate Agreement, as described in detail below: Breach Detail Date of Breach Date of Discovery of Breach Information about the Breach Type of Breach: Lost or stolen laptop, computer, flash drive, disk, etc. Stolen password or credentials Unauthorized access by an employee or contractor Unauthorized access by an outsider Other (describe) Detailed Description of the Breach Types of Unsecured Protected Health Information involved in the breach (such as Full Name, SSN, Date of Birth, Address, Account Number, Disability Code, etc). Personal Information: Health Information: Name Basic information (age, sex, height, Address etc) Date of birth Disease or medical conditions Social Security number Medications Drivers license or identification card Treatments or procedures number Immunizations Financial insurance information Allergies (credit card number, bank account Information about children number, etc) Test results Health insurance information Hereditary conditions (insurance carrier, insurance card Mental health information number, etc) Information about diet, exercise, Other Personal or Health weight, etc) Information (describe): Correspondence between patient, or medical power of attorney
Contact’s Email: Contact’s Telephone No: Business Associate hereby notifies FHKC that there has been a Breach of Unsecured (unencrypted) Protected Health Information that Business Associate has used or has had access to under the terms of the Business Associate Agreement, as described in detail below: Breach Detail Date of Breach Date of Discovery of Breach Information about the Breach Type of Breach: Lost or stolen laptop, computer, flash drive, disk, etc. Stolen password or credentials Unauthorized access by an employee or contractor Unauthorized access by an outsider Other (describe) Detailed Description of the Breach Types of Unsecured Protected Health Information involved in the breach (such as Full Name, SSN, Date of Birth, Address, Account Number, Disability Code, etc). Personal Information: Name Address Date of birth Social Security number Drivers license or identification card number Financial insurance information (credit card number, bank account number, etc) Health insurance information (insurance carrier, insurance card number, etc) Other Personal or Health Information (describe): Health Information: Basic information (age, sex, height, etc) Disease or medical conditions Medications Treatments or procedures Immunizations Allergies Information about children Test results Hereditary conditions Mental health information Information about diet, exercise, weight, etc) Correspondence between patient, or medical power of attorney
Revised-Draft-ITN-Contract-Draft-B.docx