Contact Us
Please provide your company and personal details, along with the information you are seeking.
Company Name
*
Company Email Address
example@example.com
Company Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What information or data do you need?
*
ACKNOWLEDGEMENTS
I understand the restrictions on submitting PHI (Protected Health Information) through this form
*
I understand the restrictions on submitting PHI (Protected Health Information) through this form
I consent to be contacted regarding my submission
*
I consent to be contacted regarding my submission
ORGANIZATION INFORMATION
Legal Company Name
*
Organization Type
*
Primary Location
*
States of Operation
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
NPI (National Provider Identifier)
EIN / Tax ID
Website
PRIMARY CONTACT INFORMATION
Name
*
First Name
Last Name
Title / Role
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time to Contact
Please Select
Morning
Afternoon
Evening
OPERATIONS & BUSINESS DEMOGRAPHICS
Patients Served Annually
Claims Submitted Annually
Number of Employees
Third-party or Billing Company
Yes
No
Billing Federal Healthcare Programs
Yes
No
Unsure
Insurance Carriers Accepted
EHR / Practice Management System
Billing Platform / Clearinghouse
COMPLIANCE HISTORY
Date of Last Compliance Risk Assessment
-
Month
-
Day
Year
Date
Date of Last HIPAA Security / Privacy Assessment
-
Month
-
Day
Year
Date
Date of Last SOX / SOC Audit
-
Month
-
Day
Year
Date
External Audits or Investigations
Yes
No
Formal Compliance Program
Yes
No
Written Policies and Procedures
Yes
No
Annual Compliance Training
Yes
No
POTENTIAL SERVICES OF INTEREST
Compliance Services Interested In
Compliance Program Development
Compliance Risk Assessment
HIPAA Security and Privacy
SOX/SOC Audits
External Audits
Training and Education
Policy Development
Other
Other Services Description
READINESS & CONTRACT FIT
Desired Start Timeline
Immediately
Within 1 Month
Within 3 Months
Within 6 Months
More than 6 Months
Estimated Monthly Compliance Budget
Less than $5,000
$5,000 - $10,000
More than $10,000
Decision Maker
Yes
No
Urgent Compliance Issues
Yes
No
CURRENT CONCERNS / GOALS
Description of Current Concerns or Goals
ADDITIONAL NOTES (OPTIONAL)
I certify that the information provided is accurate to the best of my knowledge.
Signature
Date
-
Month
-
Day
Year
Date
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