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HIPAA Privacy Questionnaire (Nelson Mullins).lhc-forms.json
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window.formDef = {
"code": "Q-001",
"name": "Privacy CheckSheet",
"units": null,
"hideUnits": true,
"templateOptions": {
"obrHeader": false,
"hideHeader": true,
"allowMultipleEmptyRepeatingItems": false,
"hideUnits": true
},
"items": [
{
"question": "Please provide the details",
"header": true,
"hideUnits": true,
"questionCode": "token",
"localQuestionCode": "token",
"units": null,
"codingInstructions": "",
"copyrightNotice": null,
"items": [
{
"question": "Name",
"questionCode": "token-name",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "token-name",
"dataType": "ST",
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "Email",
"questionCode": "token-email",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "token-email",
"dataType": "EMAIL"
},
{
"question": "Token",
"questionCode": "token-token",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "token-token",
"dataType": "ST"
}
]
},
{
"question": "From whom you receive or access or for whom you collect",
"header": true,
"hideUnits": true,
"questionCode": "I",
"localQuestionCode": "I",
"units": null,
"codingInstructions": "For each entity from whom you receive or access, or for whom you collect, protected health information, provide the following information",
"copyrightNotice": null,
"items": [
{
"question": "Name",
"questionCode": "pr. a",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.a",
"dataType": "ST"
},
{
"question": "Type Of Entity?",
"questionCode": "pr. toe",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.toe",
"dataType": "ST"
},
{
"question": "Is this a Covered Entity?",
"questionCode": "pr.a",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.a",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "Is this a business associate?",
"questionCode": "pr.be",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.be",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": " Is this part of an Organized Health Care Arrangement?",
"questionCode": "pr.oha",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.oha",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "Address and contact information",
"questionCode": "pr.address",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.address",
"dataType": "TX"
}
]
},
{
"question": "Purpose of collection/access/receipt of PHI",
"questionCode": "pr.purpose",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.purpose",
"dataType": "ST"
},
{
"question": "Describe the type of information you receive",
"questionCode": "pr.describeinfo",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.describeinfo",
"dataType": "TX"
},
{
"question": "For each type of information you receive, what do you do with it?",
"questionCode": "pr.receive",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "pr.receive",
"dataType": "TX"
},
{
"question": "Add url of Agreements data sharing with, or for, the entity",
"questionCode": "pr.addurl",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"codingInstructions": "Attach any agreements for data sharing with, or for, the entity (e.g., business associate agreement, data use agreement, authorizations, etc.). If this involves authorizations or another type of document that you collect from numerous individuals, attach the form template",
"localQuestionCode": "pr.addurl",
"dataType": "TX"
},
{
"question": "To whom you send or allow access to PHI, or who collects PHI on your behalf",
"header": true,
"hideUnits": true,
"questionCode": "II",
"localQuestionCode": "II",
"units": null,
"codingInstructions": "For each entity to whom you send or allow access to PHI, or who collects PHI on your behalf, provide the following information",
"copyrightNotice": null,
"items": [
{
"question": "Name",
"questionCode": "II1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II1",
"dataType": "ST"
},
{
"question": "Type Of Entity?",
"questionCode": "II2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II2",
"dataType": "ST"
},
{
"question": "Is this a Covered Entity?",
"questionCode": "II3",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II3",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": " Is this a business associate?",
"questionCode": "II4",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II4",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "Address and contact information",
"questionCode": "II5",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II5",
"dataType": "TX"
},
{
"question": "Purpose of sharing of PHI",
"questionCode": "II6",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II6",
"dataType": "TX"
},
{
"question": " Describe the type of information you send/allow access/have collected",
"questionCode": "II7",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II7",
"dataType": "TX"
},
{
"question": "For each type of information, what does the entity do with it?",
"questionCode": "II8",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II8",
"dataType": "ST"
},
{
"question": " Attach any agreements for data sharing with, or for, the entity (e.g., business associate agreement, data use agreement, authorizations, etc.). If this involves authorizations or another type of document that you collect from numerous individuals, attach the form template",
"questionCode": "II9",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "II9",
"dataType": "TX"
}
]
},
{
"question": "Accept requests from individuals for restrictions on the use or disclosure of PHI",
"header": true,
"hideUnits": true,
"questionCode": "III",
"localQuestionCode": "III",
"units": null,
"codingInstructions": "For each entity to whom you send or allow access to PHI, or who collects PHI on your behalf, provide the following information",
"copyrightNotice": null,
"items": [
{
"question": "Do you accept requests from individuals for restrictions on the use or disclosure of PHI?",
"questionCode": "III1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "III1",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "",
"header": true,
"hideUnits": true,
"questionCode": "IIISUB",
"localQuestionCode": "IIISUB",
"units": null,
"codingInstructions": null,
"copyrightNotice": null,
"skipLogic": {
"conditions": [
{
"source": "III1",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"items": [
{
"question": "Under What Circuimstances",
"questionCode": "IIISUB1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "IIISUB1",
"dataType": "TX"
},
{
"question": "What restrictions have you accepted?",
"questionCode": "IIISUB2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "IIISUB2",
"dataType": "TX"
}
]
},
{
"question": "Do you communicate those restrictions to others (BAs, ACEs, others?)",
"questionCode": "III2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "III2",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "",
"header": true,
"hideUnits": true,
"questionCode": "III2SUB",
"localQuestionCode": "III2SUB",
"units": null,
"codingInstructions": null,
"copyrightNotice": null,
"skipLogic": {
"conditions": [
{
"source": "III2",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"items": [
{
"question": "To whom and how?",
"questionCode": "III2SUB1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "III2SUB1",
"dataType": "TX"
}
]
}
]
},
{
"question": "Sell PHI or allow others to sell PHI that you collect or disclose",
"header": true,
"hideUnits": true,
"questionCode": "IV",
"localQuestionCode": "IV",
"units": null,
"copyrightNotice": null,
"items": [
{
"question": "Do you sell PHI or allow others to sell PHI that you collect or disclose?",
"questionCode": "IV1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "IV1",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "",
"header": true,
"hideUnits": true,
"questionCode": "IV1SUB",
"localQuestionCode": "IV1SUB",
"units": null,
"codingInstructions": null,
"copyrightNotice": null,
"skipLogic": {
"conditions": [
{
"source": "IV1",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"items": [
{
"question": "To whom?",
"questionCode": "IV1SUB1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "IV1SUB1",
"dataType": "TX"
},
{
"question": "For what purpose?",
"questionCode": "IV1SUB2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "IV1SUB2",
"dataType": "TX"
},
{
"question": "Add url of any agreements for the sale of PHI",
"questionCode": "IV1SUB3",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"codingInstructions": "Attach any agreements for the sale of PHI.",
"localQuestionCode": "IV1SUB3",
"dataType": "TX"
}
]
}
]
},
{
"question": "Employees",
"header": true,
"hideUnits": true,
"questionCode": "V",
"localQuestionCode": "V",
"units": null,
"copyrightNotice": null,
"items": [
{
"question": "Do you have employees?",
"questionCode": "V1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "Employee",
"header": true,
"questionCardinality": {
"min": "1",
"max": "*"
},
"hideUnits": true,
"questionCode": "V1SUB",
"localQuestionCode": "V1SUB",
"units": null,
"codingInstructions": "",
"copyrightNotice": null,
"skipLogic": {
"conditions": [
{
"source": "V1",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"items": [
{
"question": "Type of employee",
"questionCode": "V1SUB1-type",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB1-type",
"dataType": "CWE",
"answerCardinality": {
"min": "1",
"max": "*"
}
},
{
"question": "a. Job Description",
"questionCode": "V1SUB1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB1",
"dataType": "TX"
},
{
"question": "b. Does this job involve accessing, using, or disclosing PHI?",
"questionCode": "V1SUB2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB2",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "i. Are there restrictions on which PHI the employee can access?",
"questionCode": "V1SUB2-1",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB2",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-1",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "ii. Does this job involve treatment of individuals?",
"questionCode": "V1SUB2-2",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB2",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-2",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "iii. Does this job involve payment operations (billing, collections, etc.)",
"questionCode": "V1SUB2-3",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB2",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-3",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "iv. Does this job involve any of the following: quality assessment and improvement activities; reviewing the competence or qualifications of health care professionals; underwriting, enrollment, premium rating or other activities related to health insurance or benefit contracts; medical review; legal services; auditing functions; business planning and development; business management and general administrative activities; or creating de-identified health information?",
"questionCode": "V1SUB2-4",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB2",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-4",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "c. Do you have a Security Officer?",
"questionCode": "V1SUB3",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB3",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "i. Name",
"questionCode": "V1SUB2-11",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB3",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-11",
"dataType": "ST"
},
{
"question": "ii. Describe duties or attach a job description",
"questionCode": "V1SUB2-12",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB3",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-12",
"dataType": "ST"
},
{
"question": "iii. Is this individual listed in any corporate minutes or on the company's website or other materials?",
"questionCode": "V1SUB2-13",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB3",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB2-13",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "d. Do you have a Privacy Officer?",
"questionCode": "V1SUB4",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB4",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "i. Name",
"questionCode": "V1SUB4-11",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB4",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB4-11",
"dataType": "ST"
},
{
"question": "i. Describe duties or attach a job description",
"questionCode": "V1SUB4-12",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB4",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB4-12",
"dataType": "ST"
},
{
"question": "iii. Is this individual listed in any corporate minutes or on the company's website or other materials?",
"questionCode": "V1SUB4-13",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [
{
"source": "V1SUB4",
"trigger": {
"code": "Y"
}
}
],
"action": "show"
},
"localQuestionCode": "V1SUB4-13",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "e. Do you have other individuals who, as part of their jobs, are involved in oversight or implementation of compliance activities? Yes",
"questionCode": "V1SUB5",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"localQuestionCode": "V1SUB5",
"dataType": "CNE",
"answers": [
{
"text": "Yes",
"code": "Y"
},
{
"text": "No",
"code": "N"
}
],
"answerCardinality": {
"min": "1",
"max": "1"
}
},
{
"question": "i. Provide or attach a job description",
"questionCode": "V1SUB5-11",
"header": false,
"hideUnits": false,
"noEmptyValue": true,
"skipLogic": {
"conditions": [