Legal Practice Name

Practice ID

Owner Name

HIPAA Privacy Officer

HIPAA Privacy Officer email

HIPAA Security Officer

HIPAA Security Officer email

Incident Response Team Members

Operating System

Anti-virus software

Will your organization/ practice complete HIPAA training?

Dental Software

All Software Uses PHI

How often is your Data backed up?

Data backup isSelect...OnsiteOffsiteBoth

Is your back up encrypted?Select...YesNo

Date of most recent security assessment

IT Emergency Contacts