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Request Proposal Form
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Request Proposal Form
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1. Please enter your organization name
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2. Please provide your Name
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3. Please provide your Title
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4. Please provide your email address
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5. Please provide your phone number
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6. Please provide your address
7. Number of employees
8. What type of organization are you?
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Provider
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Business Associate
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General Assessment Information
9. What is the time-frame for the project to begin?
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Next 30 days
Next 3 months
Next 6 months
10. Select the regulations your organization must comply with
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HITECH Breach
CCPA
HITRUST
PCI DSS
GDPR
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11. Is there a date the project must be completed by?
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12. Has the project been budgeted?
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13. How can we help you?
I need a Risk and/or Cybersecurity (Technical Vulnerability) Assessment
I need a HIPAA Risk and/or Cybersecurity (Technical Vulnerability) Assessment
I only need a Cybersecurity Assessment
I want your help with something else
Thanks for providing all that information!
HIPAA Risk Assessment Details
14. Have your HIPAA Policies and Procedures been reviewed, updated & approved in the last 12 months?
Yes
No
Maybe
15. What was the date of your last HIPAA Risk Assessment?
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Pick a date
16. Do you have a Business Associate Agreement template?
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17. Would you like to include a Cybersecurity (Technical Vulnerability) Assessment?
Yes, include a Cybersecurity Assessment
No, do not include a Cybersecurity Assessment
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