Healthcare HIPAA Risk Assessment | HIPAA Compliancy Software

Below is our healthcare HIPAA Risk Level Evaluation. It’s a 31 question Privacy and Security Assessment / Gap Questionnaire that will take approximately 15 minutes to complete. At the end we will ask for a company name and email and give you a detailed report immediately. The report is a graphical analysis that shows where you are with HIPAA compliance. For each question answered, the report will give you a risk level, a detailed explanation and full recommendations based on how you answered each question. Enjoy!

To which of the following items of PHI do you have access? Please check all that apply
Names	All geographic subdivisions/addresses smaller than a State
All elements of dates (except year)	Telephone numbers
Fax numbers	Electronic mail addresses
Social Security numbers	Medical record numbers
Health plan beneficiary numbers	Account numbers
Certificate/license numbers	Vehicle identifiers and serial numbers, including license plate numbers
Device identifiers and serial numbers	Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers	Biometric identifiers, including finger and voice prints
Full face photographic images and any comparable images	Genetic data
Please list any previously unmentioned PHI to which you have access (separate by commas). If none exist, leave blank.

Select one of the following which best describes your company's access to your client's protected health information (PHI).
You store the PHI on your own systems (e.g. servers, laptops, USB drives, etc.) and you also do business processing with the PHI for your client. The PHI is encrypted.
You store the PHI on your own systems (e.g. servers, laptops, USB drives, etc.) and you also do business processing with the PHI for your client. The PHI is NOT encrypted.
You store the PHI for your client in a type of data warehouse, but you do not access the data to do any business processing, and the data is encrypted. PHI in your possession is never stored on endpoints (e.g. laptops, USB drives, etc.).
You store the PHI for your client in a type of data warehouse, but you do not access the data to do any business processing, and the data is NOT encrypted.
You access PHI on your client's system through some type of secured remote access connection (e.g. VPN or dedicated line), but you never store the PHI on any of your own systems or storage devices.
You must go to your client's facilities to access the PHI, but you cannot remove any PHI or access it from a remote location.

Name the formally designated person or position that serves as your organization's privacy and security officer, or otherwise has assigned responsibility for privacy and security. If none, leave blank.
When was the last time you updated your documented privacy and information security policies and procedures?
Less than 12 months ago
1 - 2 years ago
3 - 5 years ago
More than 5 years ago
We donot have any documented policies or procedures
Describe how the privacy and information security policies and procedures are communicated to all personnel, and made available for them to review at any time. Check all that apply.
Via Email	Put on Company Intranet
Put on Internet Site	Distribute Printed Copies
Make Available in Management Policy Binders	Some Other Method
Policies and procedures are not communicated or provided
Do you provide regular training and ongoing awareness communications for information security and privacy for all your workers.
Yes
No
We do some awareness communications, but not formal training
We have done some training, but not regularly. And we do not provide awareness communications.
Provide the date for the most recent information security and privacy training.
Less than 6 months ago
6 - 12 months ago
1 - 2 years ago
More than 2 years ago
We've never done any formal training or providing formal training modules
When did you perform your most recent information security risk assessment? NOTE: This compliance assessment you are currently taking is NOT a full security risk assessment, so do not count this as your most recent security risk assessment.:
Less than 12 months ago
1 - 2 years ago
3 - 5 years ago
More than 5 years ago
We've never done a risk assessment
When was the last time you performed a vulnerability assessment or penetration scan on your networks and systems? NOTE: These are typically automated scans, and are not the same as a full security risk assessment.
Less than 12 months ago
1 - 2 years ago
3 - 5 years ago
More than 5 years ago
We've never performed a vulnerability assessment or penetration scan on our networks and systems.
Do you require all types of sensitive information, including personal information and health information, to be encrypted when it is sent through public networks and when it is stored on mobile computers and mobile storage devices?
Yes
No
In some storage or through public networks, but not both, or in some cases but not others.
Do you require information, in all forms, to be disposed of using secure methods?
No
Yes
For some forms, but not all
Do you have a documented security event monitoring, security incident plan, and breach response and notification plan, and teams or staff to support the plan?
Yes
No
We've thought about having such plans, and know who to call, but nothing is formally documented.
We have half of these, but have more work to do.
External Parties: Do you outsource any activities involving protected health information (PHI) or other confidential information obtained from the covered entity?
Yes
No
Not Sure
If yes to above, does your organization have Business Associate agreements in place with each of these third parties?
Yes
No
Not sure; we may have some in place but probably not all
Do you follow a process to identify new data protection legal requirements? (e.g., new state breach notification requirements)?
Yes
No
We try to do what we're supposed to, but it is not a formal comprehensively documented procedure.
We have an outside lawyer that we depend upon to tell us our legal requirements. We do not know if they have a formally documented procedure to do so, though, and hope that they would let us know when some new data protection requirement comes up.
Check all the following standards and regulations for which you can verify compliance:
HIPAA/HITECH	ISO/IEC 27001
PCI-DSS	COPPA
Applicable state breach notice laws	Other
None

Does your organization perform background checks to examine and assess an employee's or contractor's work and criminal history?
Yes
No
We are a small organization of 1-5 persons and are not planning to hire anyone in the future, so this action is not applicable to our business.
Are your employees required to sign a non-disclosure agreement upon hire, and then again annually?
Yes
No
We are a small organization of 1-5 persons and are not planning to hire anyone in the future, so this action is not applicable to our business.
Do you have a formal process to manage the termination and/or transfer of employees?
Yes
No
We are a small organization of 1-5 persons and are not planning to hire anyone in the future, so this action is not applicable to our business.
Do you have physical security controls (e.g., door locks) to prevent unauthorized access to facilities and a facility security plan?
Yes
No
We are a small organization of 1-5 persons, we all work from our homes, and are not planning to hire anyone in the future, so this action is not applicable to our business.
Do you have controls on systems and networks that host, process and/or transfer sensitive information, including the use of firewalls and controls for protecting network devices from unauthorized access and data-theft?
Yes
We have some of these controls in place, but not all of them.
No, we have one or none of these types of controls in place.
We use a managed systems provider (MSP) that is responsible for and manages all the systems and networks we use for our business. So this action is not applicable to our business; it is the responsibility of the MSP.
Are connections to your networks and systems logged and monitored?
Yes
We do some logging, but we don't log everything involving all types of access to PHI on systems and networks.
No
We use a managed services provider (MSP) so we are not sure, but we think they are
Do you have a formal access authorization process based on 'least privilege' (employees are granted the least amount of access possible in order to perform their assigned duties) and need to know (access permissions are granted based upon the legitimate business need of the user to access the information)?
Yes
We have a loose rule about this, but we do not have a formal access authorization procedure in place.
No
We are a small organization of 1-5 persons, we all need access to all data to run our business and fulfill business obligations, and are not planning to hire anyone in the future, so this action is not applicable to our business.
Do you require each user ID to be unique and not shared with others, and have a process to remove them when the user leaves the organization?
Yes
For the most part. But we have one or a very few IDs we share.
No
Have you implemented anti-malware (e.g., anti-virus, spam filters, etc.) on your computers and supporting systems?
Yes
We have some anti-malware tools in place on our systems and personal computers, but we should implement more to cover everything.
No
We use a managed services provider (MSP) to do all our computing activities, so they need to have anti-malware in place, not us.
Media handling: Do procedures exist to protect documents (e.g., paper files, prescription labels, print materials, etc.) and computer media (e.g., tapes, disks, CD-ROMs, etc.), from unauthorized disclosure, modification, removal, and destruction? Is sensitive data encrypted when stored on laptop, desktop and server hard drives, flash drives, backup tapes, etc.?If the answer is "No" to either of these questions, answer "No".
Yes
No
We use a managed services provider (MSP) to do all our computing activities, so they need to have media handling procedures in place, not us.
Segregation of Computing Environments: Are development, test and production environments separated from operational IT environments to protect production (actively used) applications from inadvertent changes or disruption? Are the data files of your business clients segregated from one another? If the answer to either question is "No" indicate "No" as your answer. Or, is this not applicable at your organization?
Yes
No
We use a managed systems provider (MSP) and are not sure, but we think they are.
We are a small organization of 1-5 persons, do not use an MSP, and we do not create software, so this action is not applicable to our business.
Segregation of Duties: Are duties separated, where appropriate, to reduce the opportunity for unauthorized modification, unintentional modification or misuse of the organization's IT assets? Or, is this not applicable at your organization?
Yes
No
We are a small (e.g., 1 - 5 person) business and we all know each other well and perform many different duties, so this action is not feasible to our business.
Change Management: Do formal change management procedures exist for networks, systems, desktops, software releases, deployments, and software vulnerability (e.g., virus or spyware) patching activities? Or, is this not applicable at your organization?
Yes
No
We use a managed systems provider (MSP) and are not sure, but we think they are
How would you evaluate your current implementation of all of the above controls?
Just getting started, but have some of the controls fully implemented.
Have around half to most of the controls implemented, but still have some work to do
Have fully implemented all the controls and is now managing ongoing compliance.
Could you provide documentation (e.g., information security policies, supporting business documentation, etc.) for all the controls above within 24 hours or request?
Yes
For most of the controls above, but some would take longer
No, we still need to do a lot of documentation, but we're working on it.