HIPAA Compliance Service Request Form
Name
*
Company name
*
Your Title
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Website
Number of employees
*
Number of Locations
*
Total Health Records (for risk calculation)
*
Annual Revenue (for risk calculation)
*
Number of Workstations used (laptops, desktops, tablets)
*
Please answer the following questions:
*
Rows
Yes
No
Have you performed a formal Security Risk Assessment (SRA) in past 24 months?
Have you performed a Cybersecurity Risk Assessment (CSRA) on your technology in past 24 months?
Do you have a cybersecurity and compliance partner working with your office?
Do you have Managed IT Service provider for your office (dedicated IT Partner)?
Do you have a documented Business Continunity Plan?
Do you have a Business Associate Agreement (BAA) on file for all Business Associates?
Please provide more details about your reason for contacting us? How can we assist you, and what specific challenges are you facing with HIPAA Compliance?
Submit
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