Healthcare Compliance Forms and Tools

Privacy Incident Questionnaire

Reference Number: _______

Date: ____________

Instructions: Pursuant to the organization’s privacy policy, “Reporting Violations and Mitigation of Harm,” the Privacy Department is responsible for conducting an investigation once a privacy incident has been discovered and/or reported. In order for a thorough investigation to be conducted, please provide all information requested below. In addition, retaliation against any person involved or believed to be involved with this investigation is a serious violation of Human Resources’ “Anti-Harassment and Retaliation Policy” and may be cause for immediate termination of employment.

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 truthful, accurate, and complete answers, and that if we discover that you did not provide truthful and complete answers, it will be grounds for discipline, up to and including termination? ___Yes ___No

7. Have you reviewed the organization’s Health Insurance Portability and Accountability Act 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 PHI means information records in any form or medium that identify 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 healthcare of the patient? PHI may include, but is not limited to, the patient’s name, address, telephone number, diagnosis, physician’s evaluation, medical treatment, and billing information. ___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 hard copy, verbal, or electronic, in order to view, know, or discuss the above-named patient’s PHI? ___Yes ___No

    1. If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. Has anyone, other than the patient, disclosed the patient’s information to you? ___Yes ___No

    1. If so, who, and what did they tell you? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Have you disclosed any of the patient’s PHI to anyone? ___Yes ___No

    1. If yes, to 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 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 the organization 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 using 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 the organization’s 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: ______________