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    Forms

     

     

    Compliance

    • Vendor Attestation of Compliance (Exec Only)

    • Business Associate HIPAA Compliance (Exec Only)

    • Compliance Audit Self-Assessment & Attestation (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)

    • 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)

    • Integrate Requests (All Staff)

    Procedural

    • 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

    Operations

    • Care Grant Request Form (v2018)

    • Care Grant Process (v2018)

    • My Healthy Child Funding Request (v2019)

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