HITRUST AI Risk Management Assessment Proposal Form

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HITRUST AI Risk Management Assessment Proposal Form

HITRUST AI Risk Management Assessment Proposal Form

1. Organization Name*

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2. Name*

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3. Title*

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4. Email*

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5. Phone* Phone Number format should be in (eg: 585.313.2336)

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6. Website*

Enter valid domain

7. Address*

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8. City*

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9. State*

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10. Country*

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11. ZIP*

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12. Number of Employees*

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13. Does your organization have a MyCSF Subscription? Yes No

14. If your organization is a Healthcare - focused business, what is the entity type? Covered Entity Business Associate Other

15. What line of business best describes your organization? Health Plan / Insurance / PBM Medical Facility / Hospital Physician Practice Pharmacy Company Health Information Exchange (HIE) Bio Tech IT Service Provider Non-IT Service Provider Third-Party Processor Other

16. Which locations will be included in the assessment scope? USA Only - single location USA Only - multiple locations, same state USA Only - multiple locations / multiple states USA & Off-shore Offshore Only

17. Does your organization have the current HIPAA certification? Yes No

18. What is the business driver for the Assessment? Contract / Business Requirement To demonstrate risk management posture to the Board/Business Partners Other

19. Time frame for project Next 30 days Next 3 months Next 6 months

20. Identify the AI areas that ecfirst can assist you with? Proposal for Risk Management Proposal for AI Cybersecurity certification Other