HIPAA Improper Disclosure Form

Incidental or accidental disclosures will occur from time to time. However, regardless of the quantity or type of protected health information (PHI) disclosed, it is important to report the event to remain compliant, to identify a potential problem in how we handle PHI, and to correct the problem related to storage, sharing, or reviewing processes.

Reporting improper disclosures does not lead to an automatic penalty. Rather, not reporting events could have serious consequences, such as a shutdown of all research at the University of Michigan-Flint. Please feel comfortable to come forward with any disclosure regardless of how significant the release of information may appear.

You candownload the Improper Disclosure Form in PDF formatand send the information to the Urban Health and Wellness Center Administrative Director by fax at 810.424.5288 or to the SHPS Dean by fax at 810.237.6532.