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1. The HIPAA Compliance Officer shall then initiate an investigation to determine whether <br /> an actual breach has occurred and what actions, if any, are necessary. <br /> 2. The HIPAA Compliance Officer shall interview all necessary parties who may have <br /> information about the incident. The staff member who reported the suspected incident <br /> and other members with knowledge of the incident should be asked to complete North <br /> State Medical Transport's "Internal Breach Incident Reporting Form." Staff members <br /> should be required to convey all information that they know about the incident and to <br /> cooperate in any subsequent investigation regarding the incident. <br /> 3. After gathering all available information about the incident,the HIPAA Compliance <br /> Officer shall conduct an analysis to determine whether an actual breach of unsecured <br /> PHI occurred. North State Medical Transport shall consult with legal counsel whenever <br /> necessary in making this determination. The HIPAA Compliance Officer shall utilize <br /> North State Medical Transport's "HIPAA Compliance Officer Action Plan: Breach Analysis <br /> Steps" in making this determination. <br /> 4. If the Compliance Officer determines that a breach of unsecured PHI has not occurred, <br /> the reasons behind that conclusion shall be thoroughly documented. <br /> 5. If the HIPAA Compliance Officer determines that a breach of unsecured PHI has <br /> occurred,theneasonubehindthatoono|usionshaUb�thonmu�h|ydo�urnentedandthe <br /> HIPAA Compliance Officer shall proceed to notify all necessary parties in accordance <br /> with this policy. <br /> Breach Notification to Affected Individuals <br /> 1. Following the discovery of a breach of unsecured PHI, North State Medical Transport will <br /> notify each individual whose unsecured PHI has been, or is reasonably believed to have <br /> been, accessed, acquired, used, or disclosed as a resultof such breach. The HIPAA <br /> Compliance Officer shall be the party who is primarily responsible to make proper <br /> notice, in consultation with North State Medical Transport management. <br /> 2. A breach shall be treated as discovered by North State Medical Transport as of the first <br /> day on which the breach is known, or, by exercising reasonable diligence would have <br /> been known to North State Medical Transport or any person, other than the person <br /> committing the breach,who is a staff member or agent of North State Medical <br /> Transport. <br /> 3. North State Medical Transport shall provide the notification without unreasonable delay <br /> and in no case later than 60 calendar days after discovery of a breach <br />