HIPAA-Enabled Payment Processing Software Evaluation Form
Use this form to evaluate software for healthcare payment processing, including compliance readiness, security, integrations, workflow fit, support, and implementation needs.
Evaluation Context
Organization Name
*
Evaluator Name and Role/Title
*
Organization Type
*
Provider
Clinic
Hospital
Dental
Behavioral Health
Billing Service
Other
Approximate Monthly Payment Volume
*
Please Select
Under 1,000
1,000–4,999
5,000–9,999
10,000–24,999
25,000+
Other
Primary Use Case for the Software
*
Patient Payments
Claims-Related Patient Responsibility
Recurring Billing
Payment Plans
Refund Handling
Multi-Location Payments
Other
HIPAA and Security Readiness
HIPAA/security readiness
*
Low readiness
1
2
3
4
High readiness
5
1 is Low readiness, 5 is High readiness
Access controls and role-based permissions
*
Yes
Partial
No
Audit logging availability
*
Yes
Partial
No
Encryption in transit and at rest
*
Yes
Partial
No
Business associate agreement availability
*
Yes
No
Not sure
Incident response/support documentation upload
Upload a File
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Payment Processing Capabilities
Supported Payment Methods Needed
*
Credit card
Debit card
ACH/bank transfer
HSA/FSA card
Payment plan
Recurring payments
Other
Refund/Void Workflow Fit
*
Excellent fit
Acceptable with configuration
Limited fit
Not supported
Other
Test/Reference Payment Detail (Last 4 Digits Only)
Patient Responsibility Estimates or Partial Payments
*
Yes
Partial
No
Other
Integrations and Workflow Fit
Current EHR/Practice Management System Name
Required Integrations
*
EHR
Practice Management
Clearinghouse
Accounting
CRM
Patient Portal
Web Forms
Other
API or Single Sign-On Needed?
*
Yes
No
Unknown
Implementation Timeline Preference
*
Please Select
Immediate
Within 30 Days
Within 60 Days
Within 90 Days
Flexible
Other
Workflow Fit Ratings
*
Rows
Poor
Fair
Good
Very Good
Excellent
Onboarding
1
2
3
4
5
Payment Posting
6
7
8
9
10
Reporting
11
12
13
14
15
Reconciliation
16
17
18
19
20
User Experience
21
22
23
24
25
Support, Reporting, and Vendor Evaluation
Required Support Hours / Time Zone
*
Please Select
U.S. Eastern
U.S. Central
U.S. Mountain
U.S. Pacific
UTC
Other
Reporting Needs
Transaction reporting
Refund reporting
Aging/balances
Reconciliation
Downloadable exports
Custom reports
Implementation / Training Needs
Self-service only
Standard onboarding
Hands-on implementation support
On-site or extended training
Other
Overall Vendor Rating - Usability
1
2
3
4
5
Overall Vendor Rating - Compliance Confidence
1
2
3
4
5
Overall Vendor Rating - Support Quality and Value
1
2
3
4
5
Submit Evaluation
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