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HIPAA Improper Disclosure Form

Please report any improper disclosure of PHI (Protected Health Information) using the form below. 

Your Name:
*Your Email:
 Required
Please describe the disclosure:
*Please re-enter your email for confirmation:
Disclosure Date:
(mm/dd/yyyy)
Please select the type of disclosure:
Has the disclosed PHI been recovered?:
YES
Please provide a phone number we may contact you at if necessary:
NO
TS4MO has a strong commitment to protecting your privacy and maintaining complete data security.

Our Privacy Policy will inform you of the information we collect and how we protect it. It will help you better understand our commitment to your privacy and data security and how you can help us honor that commitment.       Our Privacy Policy





Our Notice of Privacy Practices describes how TS4MO may use and disclose your protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. PHI is information about you, including demographics that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

                    Review our HIPAA Statement
HIPAA Improper Disclosure Form
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Our Affiliates                                                                                                                   TS4MO  (Technology Solutions 4 the Medical Office)  -  PO Box 2383  -  Renton, WA  98056  -  Copyright © 2006