Sample Template

							                                                                                                           SAMPLE                                                                               4/3/2011, 4:03 AM
                                                                             Breach Notification Template for PHI-PII Data Elements Spreadsheet




Instructions:
Input Patient/Reserach Subject name as written in the email.
Check box if data element is present in the email.
If person is from out of state or in a non-covered entity patient, indicate where.
If there is "other" or specific "sensitive" health information, indicate what type.

Name                         Check if data element is present in the email:

                                             Credit                                                                                                                                          Sensitive Info,
                                                                                                            Non
                                    Driver   Card #                                            Out of                                                                           Other Health i.e.,drug/alcoh
                                                        Health      Med                                   Covered
                                    Lic or   with                            Date of           State                  Telephone    Email  Medical  Lab    Treatment             information ol, mental hlth,
Last Name      First Name    SSN                      Insurance    Record            Address               Entity                                                   Medications
                                    CA ID    PIN or                           Birth          (indicate                    #       address   DX    Results    Plan                (Indicate     HIV, genetic
                                                          #          #                                     Patient
                                    #        access                                            state)                                                                             Whose)          testing
                                                                                                         (indicate)
                                             code                                                                                                                                               (indicate)




                                                                                                            Page 1 of 4
                                                                                                    SAMPLE                                                                               4/3/2011, 4:03 AM
                                                                      Breach Notification Template for PHI-PII Data Elements Spreadsheet




                                        Credit                                                                                                                                        Sensitive Info,
                                                                                                     Non
                               Driver   Card #                                          Out of                                                                           Other Health i.e.,drug/alcoh
                                                   Health     Med                                  Covered
                               Lic or   with                          Date of           State                  Telephone    Email  Medical  Lab    Treatment             information ol, mental hlth,
Last Name   First Name   SSN                     Insurance   Record           Address               Entity                                                   Medications
                               CA ID    PIN or                         Birth          (indicate                    #       address   DX    Results    Plan                (Indicate     HIV, genetic
                                                     #         #                                    Patient
                               #        access                                          state)                                                                             Whose)          testing
                                                                                                  (indicate)
                                        code                                                                                                                                             (indicate)




                                                                                                     Page 2 of 4
                                         SAMPLE                                 4/3/2011, 4:03 AM
           Breach Notification Template for PHI-PII Data Elements Spreadsheet




Comments




                                       Page 3 of 4
                                         SAMPLE                                 4/3/2011, 4:03 AM
           Breach Notification Template for PHI-PII Data Elements Spreadsheet




Comments




                                       Page 4 of 4