Get Mo Dss Mo 886-4456 2014-2025

This guide provides clear and comprehensive instructions for completing the MO DSS MO 886-4456 form online. With step-by-step directions, you will be able to effectively report any unauthorized use or disclosure of protected health information.

Follow the steps to complete the form efficiently.

1. Press the ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin by filling out the incident reporter information section, which includes your printed name, signature, position, the date the report is completed, division or work address, and telephone number.
3. Proceed to the incident information section. Answer whether the incident involves information maintained by DSS by selecting 'Yes', 'No', or 'Unknown'.
4. Indicate if the incident involves information in an electronic format with the same options as in step 3. If 'Yes', note if the electronic information was encrypted in question 2a.
5. Inquire if the incident was the result of an action by a DSS employee, intern, or volunteer. If so, provide the individual's identification.
6. Identify the DSS division, office, or unit involved in the incident and provide the office manager's name, address, and telephone number.
7. State whether the incident was caused by the action of another entity or its employee(s). If applicable, provide their details and the relationship with DSS.
8. Describe the incident thoroughly, including what happened and affected individuals' names and mailing addresses. Attach additional pages if necessary.
9. Answer whether there are 500 or more individuals involved. If applicable, attach a list of names.
10. Fill out the date(s) of the incident or when it was discovered.
11. Navigate through questions about the type of information involved in the incident. Be sure to answer each appropriately.
12. Indicate if the mailing address is unavailable for ten or more individuals.
13. Determine if law enforcement has been informed of the situation and provide their agency details if applicable.
14. Conclude by indicating if corrective action has been taken and specify what that action was.
15. Once complete, save changes, download, print, or share the form as required.

Ensure you submit the MO DSS MO 886-4456 form online for effective processing.