Survey for Obtaining Feedback on HIPAA Training for State Attorneys General & Staff and HIPAA and Security Peformance Audit Survey for Selected Covered Entities

Form Approved

OMB No. 0990-xxxx

Exp. Date XX/XX/20XX

HIPAA PRIVACY AND SECURITY PERFORMANCE AUDIT SURVEY FOR SELECTED COVERED ENTITIES

Instructions

Your organization is part of the pool of covered entities from which OCR will select the subjects of a HIPAA privacy and security performance audit. Please provide the information requested below by checking the appropriate boxes and following instructions to answer questions related to your operations. Answer questions to the best of your knowledge.

Objective

This survey is intended to gather data about the size and complexity of potential auditees subject to HIPAA privacy and security performance audits. OCR seeks to survey entities with specific organizational attributes; the information provided will assist OCR in selecting the appropriate range of entities of specified sizes and complexity. Please see the attached Protection of Information Created or Obtained Through the HIPAA Audit Program.

Information Requested

Contact Information
Name:
Title:
Covered Entity Name:
Email address:

• Entity is: (check one) Public Private

• Entity is: (check one) Multi-location Single location only

• Policies and Procedures are: (check one)

Developed and managed in-house

Dictated by parent company

• Entity Type: (check one)

Health Care Provider (Answer questions 1 – 7)

Health Plan (Answer questions 8-10)

Health Care Clearinghouse (Answer questions 11-13)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

HEALTH CARE PROVIDERS

What type of provider are you? (hospital, urgent care, skilled nursing, etc)

How many patient visits per year?

How many patient beds do you have currently?

HEALTH CARE PROVIDERS (cont’d)

What is the current number of clinicians on staff?

What is the current number of clinicians with privileges in facilities?

Do you currently use electronic medical records?

What is the total revenue for the most recent fiscal year?

HEALTH PLANS

What is the current total number of members within your health plan?

What is the total number of claims processed monthly?

What is the total revenue for the most recent fiscal year?

If you maintain a group health plan, is it fully insured?

HEALTH CARE CLEARINGHOUSES

What is the total number of transactions processed monthly?

What is the current number of providers served?

What is the total revenue for the most recent fiscal year?

Do you create or receive protected health information other than as a business associate of another covered entity?

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