HIPAA Compliance Reporting Form

NOTE: This form must be fully completed and submitted to the Privacy Officer. The form can be emailed, sent by postal service, or dropped off at Redlands Community Hospital's Reception Desk. Please direct this form to the Redlands Community Hospital Privacy Officer.

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Fields in bold are required.

Reportee First Name

Reportee Last Name

Are you the patient?

If not the patient, relationship

Reportee's Telephone Number

Reportee's Email

Please describe your concern in detail. Be sure to mention what occurred, where and when it occurred, who was involved and how did you learn about it:

Submit

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