Request Risk Assessment TMLT offers customized Medical Privacy, Security and Breach Notification Assessments. How can we help? Please complete the form below and click "Submit" when finished. Required fields are indicated with an asterisk * Please check all that apply * Security Risk Analysis for meaningful use only Complete Privacy, Security and Breach Notification Assessment Customized HIPAA training on site Basic Info First Name * Last Name * M.I. Name of Practice * Phone Number * Contact * Email Address * 1) How many business locations? * Please list addresses Address Remove Address 2 State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip City Add another address 2) Do you want a Risk Assessment for each of your locations? * Yes No Personnel 3a) Total number of physicians and staff 3b) Do you have internal IT personnel? Yes No Technology 4) How many computers? * 5a) How many are laptops? 5b) How many laptops are used outside the office? 6a) How many personnel work from home? 6b) Do they use company supplied computers? Yes No 6c) Do they print PHI at home? Yes No 7a) How many printers/fax/copiers/scanners? 7b) Are they owned/leased? Owned Leased Both 8) Do you use a data center? Yes No Please list the name and location: Software 9) Please list the Operating Systems installed on the laptops, workstations and servers. 10) Please name all Software/Applications that contain PHI. 11) Electronic health records? (EHR) Yes No What is the name of the EHR software? 12) Practice management software? (PM) Yes No What is the name of the PM software? 13) Picture archiving and communication systems? (PACS) Yes No What is the name of the PACS? 14) Do you download reports containing PHI into Excel? Yes No What reporting system is used? Security Risk Assessment (SRA) 15a) Date of last SRA performed 15b) Was SRA performed internally or by outside vendor? Internally Outside vendor 15c) Was a risk management plan developed? Yes No Policies and Procedures 16) Do you have written privacy policies? Yes No Date written/updated or revised? 17) Do you have written security policies? Yes No Date written/updated or revised?