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Get and Sign to Determine Whether a Breach Has Occurred  Form

Get and Sign to Determine Whether a Breach Has Occurred Form

Use a To Determine Whether A Breach Has Occurred template to make your document workflow more streamlined.

Unintended recipient Suspected malicious intent Yes No 4 DATA ELEMENTS Demographic Information check all that apply First name or initials Last name Date of birth CIN or Medi-Cal Driver s license Membership Mother s maiden name Image User name/email address Program name Other Financial Information check all that apply Credit card/bank acct EBT card PIN Claims information Clinical Information check all that apply Diagnosis/condition Medications Lab results TAR Psychotherapy notes Substance...
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