Forms

Compliance

• Vendor Attestation of Compliance (Exec Only)

• Business Associate HIPAA Compliance (Exec Only)

• FWA Attestation (All Staff)

• EPSDT Attestation (All Staff)

• Compliance Program Attestation (All Staff)

• SPP Certification (SPP Users)

• Policies and Procedures Acknowledgement Form (All Staff)

• Conflict of Interest Form (CBCIH Staff Only)

• Conflict of Interest Form (CBC Staff Only)

Procedural

• PQI Incident Training Acknowledgement Form (Upon Request)

• Privacy, Security Training Acknowledgement Form (Upon Request)

• Training Request Form

• Training Report Form (ver. 3.0)

• File Uploads

• Assignment Requests (CBCIH Only)

• PQI Form (CBCIH Only)

• Confidentiality Agreement (CBCIH Only)

Operations

• CBCIH-Form 1004A_HIPAA_Data Breach Reporting

• CBCIH-Form 1004B_HIPAA_Four-Factor_Risk_Assessment

• CBCIH-Form 1004C_HIPAA_Data Breach_CBCIH Follow-up

• CBCIH-Form 1007A_Sub-Delegation_Approval_Request

• CBCIH-Form 1007B_Sub-Delegation_Evaluation_Review

• CBCIH-Form 1007C_CBC Sub-Delegation_Approval_Request

• CBCIH-Form 1007D_Disclosure of Ownership

• CBCIH-Form 1007E-AHCA Level II BGS Addendum

• Care Grant Request Form (v2018)

• Care Grant Process (v2018)

• My Healthy Child Funding Request (v2019)