hipaa questionairre based on google form

	A	B	C	M
1	DO NOT FILL THIS FORM OUT. THIS IS MEANT AS A BLANK TEMPLATE. MAKE A COPY OF THIS SHEET TO PUT YOUR INFORMATION IN. THIS CAN BE DONE BY SELECTING "FILE" IN THE BAR AT THE TOP OF THE SCREEN, FOLLOWED BY SELECTING "MAKE A COPY". THIS WILL MAKE A COPY THAT WILL HAVE THE NAME "COPY OF HIPAA QUESTIONAIRRE BASED ON GOOGLE FORM". ONLY PUT YOUR INFORMATION INTO THE COPY OF THIS FORM. ANY INFORMATION PUT INTO THE TEMPLATE FORM WILL BE DELETED.
2	Entity/Program Name
3	Address
4	City			Health
5	State			Student
6	Zip Code			Finance
7	Phone			Other
8	Entity/Program Primary Contact
9	Entity/Program Contact email
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11	What type of data do you collect?
12	If other, Please elaborate			Students
13	Do you bill insurance?	No		Both
14	Does your department manage, communicate, or store Protected Health Information (PHI)?	Yes
15	Has any aspect of your managing PHI changed since last year?	No
16	Do you see students, non-students, or both?	Both		Yes
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18	If you provide healthcare to non-students, do you collect their personal health information (PHI)?		Yes	No
19	Do you transact any of that information in electronic form covered by HIPAA (or use another entity [such as a clearinghouse] to conduct covered transactions in electronic form on your behalf)?		No
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21	If you have questions on what qualifies as a covered transaction: A transaction is a covered transaction if it meets the regulatory definition for the type of transaction. Answer the following questions to determine if your transactions fall under any of the following regulatory definitions.
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23	45 C.F.R.162.1101: Health care claims or equivalent encounter information transaction is either of the following
24		Is the request to obtain payment, and necessary accompanying information, from a health care provider to a health plan, for health care?	No
25		If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, is the transaction the transmission of encounter information for the purpose of reporting health care?	No
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27	45 C.F.R.162.1201: The eligibility for a health plan transaction is the transmission of either of the following:
28		(a) An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:
29		Does your program transmit information about eligibility to receive health care under the health plan?	No
30		Does your program transmit information about coverage of health care under the health plan?	No
31		Does your program transmit information about benefits associated with the benefit plan?	No
32		(b) Does your program transmit responses from a health plan to a health care provider's (or another health plan's) inquiry described in paragraph (a) of this section?	No
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34	45 C.F.R.162.1301: The referral certification and authorization transaction is any of the following transmissions:
35		Is it a request for the review of health care to obtain an authorization for the health care?
36		Is it a request to obtain authorization for referring an individual to another health care provider?
37		Is it a response to a request described in the previous questions (above) of this section?
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39	45 C.F.R.162.1401: A health care claim status transaction is the transmission of either of the following:
40		Does your program transmit inquiries to determine the status of a health care claim?
41		Does your program transmit responses about the status of health care claims?
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43	45 C.F.R.162.1501: The enrollment and disenrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.
44		Does your program transmit subscriber enrollment information to health plans to establish or terminate insurance coverage?	Yes
45
46	45 C.F.R.162.1601: The health care payment and remittance advice transaction is the transmission of either of the following for health care:
47		The transmission of any of the following from a health plan to a health care provider's financial institution:
48		Does your program transmit payment?
49		Does your program transmit information about the transfer of funds?
50		Does your program transmit payment processing information?
51		The transmission of either of the following from a health plan to a health care provider:
52		Does your program transmit explanations of benefits?
53		Does your program transmit remittance advice?
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55	45 C.F.R.162.1701: The health plan premium payment transaction is the transmission of any of the following from the entity that is arranging for the provision of health care or is providing health care coverage payments for an individual to a health plan:
56		Does your program transmit payment?	Yes
57		Does your program transmit information about the transfer of funds?	Yes
58		Does your program transmit detailed remittance information about individuals for whom premiums are being paid?	Yes
59		Payment processing information to transmit health care premium payments including any of the following:
60		Does your program transmit payment processing information for payroll deductions?
61		Does your program transmit payment processing information for other group premium payments?
62		Does your program transmit payment processing information for associated group premium payment information?
63
64	45 C.F.R.162.1801: The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of the health plan, of either of the following for health care:
65		Does your program transmit information about claims?
66		Does your program transmit payment information?
67	If your program provides health care to non-students, and you collect their personal health information (PHI), and transact any of that information in electronic form covered by HIPAA, or use another entity (such as a clearinghouse) to conduct covered transactions (any of the transactions above) in electronic form on your behalf, your program is considered to be conducting the transaction in electronic form. If the above is true, then you need to be a named Health Care Component under the University of Alaska HIPAA Hybrid status and are subject to the HIPAA Security Rule.
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