FSOMA HIPAA Compliance Digital Security Clinic Questionnaire

Clinic Name:

Name*

First Last

Phone

Email*

Clinic Address

Street Address Address Line 2 City State ZIP Code

Clinic Type:

Does your clinic have a website?*

Yes
No

Interested in a free web development consult?*

Yes – Contact me to schedule a consult.
No

What is your clinic’s website address?

Does your clinic website have a “Contact Us” tab?

Yes
No

Does “Contact Us” use an online form to submit personal info and questions?*

Yes
No

Does your clinic website contain New Patient and Consent Forms?

Yes
No

Are these Patient and Consent Forms Fillable Online or Print Only?

Forms - Print Only
Forms - Fillable Online

Included in EMR/Patient Portal

Yes
No

Does your clinic website meet or exceed the WCAG 2.1 AA accessibility standards related to the 1990 Americans with Disabilities Act (ADA)?

Yes
No
I do not know if my website is ADA compliant

Would you like to learn more about ADA Website Accessibility and Compliance? (Free Demo)

Yes
No

Does your clinic use an EMR/EHR platform?

Yes
No

Are you interested in seeing a free demo for EMR platform?

Yes
No

Please Choose One

Does your clinic use an online Patient Scheduler Program?

Yes
No

Is the scheduler part of your EMR system?

Yes
No

Which Patient Scheduler Program is used in your clinic?

Does your Clinic send or received emails to/from patients?

Yes
No

Choose The Email Program You Use To Send And Receive Email

Does your practice use paper fax machine?

Yes
No

How is the faxed data encrypted?

faxes are encrypted
faxes are not encrypted
not sure if faxes are encrypted

Do you use a digital fax service to receive faxes via email?

Yes
No

Choose One

Have you completed your required HIPAA Security Risk Analysis for your clinic?

Yes
No

Are you aware that HIPAA laws require clinics to conduct an annual Security Risk Analysis?

Yes
No

Would you like to learn more about completing a HIPAA Security Risk Analysis for your clinic? (Free Demo)

Yes
No

Date you lasted completed a HIPAA Security Risk Analysis?

Do you send/receive text messages from patients on a personal device or web browser?

Yes
No

Would you like to learn more about secure texting for your practice?

Yes
No

Which SMS/Text service do you use?

Do you send/receive communications with your patients over social media?

Yes
No

Which media (Choose All that Apply)

Other Media:

Number of clinic staff (include yourself, other providers, plus any employees or contractors)

Does your clinic have a current HIPAA Policies and Procedures Manual: includes 1996 HIPAA Act, 2000 HIPAA Privacy Rule, 2005 HIPAA Security Rules, the 2009 HITECT Act, and 2012 Omnibus Rule?

Yes
No

Are you aware that maintaining a clinic HIPAA Policies & Procedures Manual is required by law?

Yes
No

Would you like Patient Data Protection, LLC to prepare and send a customized HIPAA Compliance Privacy and Security Rule Clinic Handbook for your office?

Yes
No

Date last updated?

Do you provide and document annual HIPAA training for all clinic staff?

Yes
No

Are you aware that state and federal law requires health care practices to provide and document annual HIPAA training for all clinic staff?

Yes
No

Would you like more information about staff HIPAA training requirements?

Yes
No

Are you No Surprise Act Compliant, with the proper use of Good Faith Estimates?

Yes
No

Questions or Comments:

Please let us know how you heard about us, or how were you directed to this questionnaire?

After you click submit, you will receive a copy of this form and the answers from support@patientdataprotection.com. Be sure to check your junk mail if you do not receive the email in your inbox. If you have any question please call 1-352-268-5088. One of our specialist will contact you shortly. We respect your privacy and will not in any way use the information you provide us for any other reason than this free assessment.

Tell us more about your practice/clinic