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About
Our Approach
Our Story
Join Us
For Families
MyCuraJOY
Youth Ambassadors
Communities
Asian
For Providers
Blog
Donate
Support
Incident Reporting Forms
HIPAA Violation Reporting Form
Person Reporting Incident
*
*
I am reporting a
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Unauthorized Access
Improper Disposal of PHI
Data Breach or Leak
Unauthorized Disclosure
Other
Other
Date / Time of Incident
*
Date
Time
*
Time
Location of Incident
*
Please describe the event in detail.
*
How Did You Beware of this Incident
*
Additional Comments:
Preferred Follow-Up Method
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Email
Text
Phone
Email
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Number
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Captcha
Submission
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I would like to remain anonymous
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