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Request Proposal Form
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Request Proposal Form
Request a Proposal
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. Website
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7. Please provide your address
8. City
*
9. Post Code
*
10. Country
*
11. State
*
12. Number of employees
13. What type of organization are you?
Hospital
Provider
Payer
Business Associate
Other
General Assessment Information
14. What is the time-frame for the project to begin?
*
Next 30 days
Next 3 months
Next 6 months
15. Select the regulations your organization must comply with
HIPAA
HITECH Breach
CCPA
HITRUST
PCI DSS
GDPR
FEDRamp
Other
16. Is there a date the project must be completed by?
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Pick a date
17. Has the project been budgeted?
Yes
No
Maybe
18. 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
19. Have your HIPAA Policies and Procedures been reviewed, updated & approved in the last 12 months?
Yes
No
Maybe
20. What was the date of your last HIPAA Risk Assessment?
/
/
Pick a date
21. Do you have a Business Associate Agreement template?
Yes
No
22. 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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