Federal Trade Commission

The nation’s consumer protection agency 

Notice of Breach of Health Information

OMB Control No: 3084-0150

(exp. 3/31/2019)

Are you in the business of offering or maintaining personal health records? Does your company offer products or services 

that interact with personal health records – for example, an online weight tracking program that sends information to a 

personal health record or pulls information from it? If that describes your line of work – and if you’re not covered by the 

Health Insurance Portability & Accountability Act (HIPAA) – the law requires you to take steps if you’ve had a breach 

involving information in a personal health record not secured in a certain way. Under the law, 16 C.F.R. Part 318, you 

must: 

1. Notify everyone whose information was breached;

2. In many cases, notify the media; and

3. Notify the Federal Trade Commission (FTC).

The FTC has designed this form to make it easier for you to report a breach to us. For more on notifying the people 

whose information was breached, visit www.ftc.gov/healthbreach. 

For all breaches

Complete this form. Include your own contact information. Don’t include any personally identifiable information involved 

in the breach. 

You have two options for submitting the form.

(1) Send it to:

Federal Trade Commission

Associate Director – HBN

Division of Privacy & Identity Protection

600 Pennsylvania Avenue, N.W.

Mail Stop CC-8232

Washington, DC 20580

Verify that the form arrived at the FTC by using a mailing method that gives you proof of delivery.

(2) Transmit your submission through our secure file transmission system. To do so, you must send an email to 

ElectronicFilings@ftc.gov (link sends e-mail) with the subject line “HBN – Request to Submit Document.” Do not 

include any details about the breach or the notification form in this request. You should receive a reply email 

within two business days with instructions for the secure electronic submission of encrypted documents.

Timelines These timelines refer to when you must notify the FTC of the breach. If the law requires you to contact the 

people whose information was breached, you must notify them as soon as you can – and no later than 60 days after 

discovering the breach.

For breaches involving the records of 500 or more people

Complete this form and send it to the FTC within 10 business days of discovering the breach.

For breaches involving the records of fewer than 500 people

Complete this form and send it to the FTC by the 60th day of the calendar year following the breach. For 

example, if you discover a breach involving fewer than 500 people on June 30, 2009, send this form to the FTC 

no later than 60 days into the calendar year of 2010. If you experience two breaches like this in one calendar 

year – one on June 30th and another on November 1st – complete a separate form for each breach, staple them 

together, and send them to the FTC no later than 60 days into the calendar year of 2010. 

Questions? Call the FTC at (202) 326-2252 or send a letter to the address above.

Paperwork Reduction Act Statement: Under the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and 

a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Notice of Breach of Health Information

Your company or organization

Name of your company or organization: Website:

Address:

City State Zip

Contact person at your company or organization:

Contact telephone: About how many employees does your company or 

organization have?

Contact email address: What products or services do you offer?

Information about the breach

Type of breach: 

Lost or stolen laptop, computer, flash drive, disk, etc.

Stolen password or credentials

Unauthorized access by an employee or contractor

Hacker

Other (describe)

Date(s) the breach happened (if you know):

From: / / To: / / 

Have you made the breach public? Yes No

If YES, when did you make it public?

Date the breach was discovered: / / 

How many individuals were affected by the breach? 

Comments: 

Type of information involved (check all that apply):

Personal Information

Name

Address

Date of birth

Social Security Number

Drivers license or identification card number

Financial information (credit card number, 

 bank account number, etc)

Health insurance information (insurance carrier, 

insurance card number, etc.)

Other Personal or Health Information

(describe):

Health Information

Basic information (age, sex, height, etc.)

Disease or medical conditions

Medications

Treatments or procedures

Immunizations

Allergies

Information about children

Test results

Hereditary conditions

Mental health information

Information about diet, exercise, weight, etc.

Correspondence between patient and providers

Living wills, advance directives, or medical 

power of attorney

Organ donor authorization
Notice of Breach of Health Information

What steps are you taking to investigate the breach?

What steps are you taking to mitigate losses?

What steps are you taking to protect against further breaches?

List any law enforcement agencies you’ve contacted about the breach. 

Breach notification

Have you notified the people whose information was breached?

YES. We notified them on:

Attach a copy of the letter to this form. Don’t include any personally identifiable information, other than your own 

contact information.

NO. Our investigation isn’t complete.

If you determine you need to notify them, as soon as you can – and no later than 60 days after discovering the 

breach – you must: 1) Notify the people whose information was breached; and 2) Send a copy of the letter to the 

FTC. Don’t include any personally identifiable information, other than your own contact information.

If you determine you don’t need to notify the people whose information was breached, send a letter to the FTC at 

the address below explaining why notification isn’t necessary.

Has anyone at your business or organization received information that someone has been harmed by this breach? For 

example, has a customer called you to complain about identity theft? Or are you aware of any public disclosure of 

information that resulted from the breach? YES NO

If YES, describe the harm you’ve found out about. Don’t include any personally identifiable information.

For FTC use:

Reference Number: __________________