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Request Proposal Form
Request Proposal Form
1. Organization Name
*
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2. Name
*
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3. Title
*
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4. Email
*
Enter valid Email
5. Phone
*
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Phone Number format should be in (eg: 585.313.2336)
6. Website
*
Enter valid domain
7. Address
*
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8. City
*
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9. Post Code
*
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10. Country
*
select
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Burkina Faso
Burundi
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Cameroon
Canada
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Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
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Eswatini
Ethiopia
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Finland
France
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Gambia
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Grenada
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Guinea-Bissau
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
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Japan
Jordan
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Kenya
Kiribati
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Korea, South
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Kuwait
Kyrgyzstan
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Latvia
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Liberia
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Nigeria
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Switzerland
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Vatican City
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11. State
*
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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
CMMC
Other
16. Is there a date the project must be completed by?
17. Has the project been budgeted?
Yes
No
Maybe
18. How can we help you?
I need a HIPAA Risk and/or Cybersecurity (Technical Vulnerability) Assessment
I only need a Cybersecurity Assessment
I want your help with something else
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?
*
21. Do you have a Business Associate Agreement template?
Yes
No
Captcha
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Thank you for contacting to us. We have received your inquiry. We will get back to you soon.