[Facility Name]: PRIVACY INCIDENT QUESTIONNAIRE
1. Employee Name:__________________
2. Employee Title: ______________________
3. Primary Department: _______________________
4. Supervisor: _____________________________________
5. Name of Patient: ___________Relationship: ____________________________
6. Do you understand that it is your obligation to provide [Facility] truthful, accurate and complete answers, and if we discover that you did not provide truthful and complete answers that it will be grounds for discipline, up to and including termination? ___Yes___No
7. Have you reviewed [Facility’s] HIPAA Privacy Policies and Procedures? ___Yes___No
8. Do you understand that any person is considered a “patient” when the person consults or is seen by a physician and/or is in this facility to receive medical care? ___Yes___No
9. Do you understand that a patient’s Protected Health Information (PHI) is confidential and may not be disclosed except with the patient’s valid, written authorization, or when necessary to provide treatment to the patient, to secure payment for the treatment services, or to enable operational support related to those services? ___Yes___No
10. Do you understand that Protected Health Information (PHI) means information records in any form or medium that identifies a patient and/or relates to the past, present, or future physical or mental health condition of the patient or relates to the payment for the health care of the patient? PHI may include, but is not limited to, the patient’s name, address, telephone number, patient diagnosis, physician’s evaluation, medical treatment, billing or other PHI. ___Yes___No
11. Were you a person called on to participate in the diagnosis and treatment of above-named patient under the direction of the attending physician? ___Yes___No
12. Were you within the course of your job duties as assigned to you by your supervisor, a person reasonably necessary for the transmission of communications regarding the above-named patient? ___Yes___No
13. Were you within the course of your job duties as assigned to you by your supervisor, a person present or necessary to further the interest of the above-named patient in consultation, examination, or interview? ___Yes___No
14. Did you access or obtain any records, or information, either hardcopy, verbal, or electronic, in order to view, know or discuss the above-named patient’s Protected Health Information? ___Yes___No
If yes, please explain:
15. Has anyone, other than the patient, disclosed the patient’s information to you? ___Yes___No
If so, who and what did they tell you?
16. Have you disclosed any of the patient’s Protected Health Information to anyone? ___Yes___No
If yes, with whom?
17. Do you agree and understand that you are not entitled to any information on any patient, unless you have been assigned to care or provide clerical or other support to the patient? ___Yes___No
18. Do you understand that all communications between the patient and any [Facility] workforce member are confidential and are not intended to be disclosed to a third person including members of the patient’s family? ___Yes___No
19. Do you understand that an employee or agent of [Facility] may only disclose a patient’s PHI with the patient’s, or the patient’s legally authorized representative’s, consent or written authorization? ___Yes___No
20. What Electronic Medical Records systems do you have access to?
21. Do you understand that your username and password are to be guarded and not shared with any other person and that you are not allowed to let any other person access the electronic medical record systems of [Facility] through your username and password? ___Yes___No
22. Please provide any additional information that may be helpful to our investigation into this matter:
I confirm that all above information provided, answers, and the comments I have made are truthful, complete and accurate. I also understand that if it is determined or if there is reason to believe that I have provided incorrect, misleading or false information, or that I have not conducted myself as required by [Facility] Code of Ethics and Business Conduct there will be disciplinary action up to and including termination of my employment.
Respondent’s Signature _______________________________________ Date______________
Interviewer’s Signature _______________________________________ Date______________
Witness’s Signature _______________________________________ Date______________