Small Physician Practice HIPAA Security Risk Assessment Form
Use this form to assess operational security risks, current safeguards, and follow-up priorities for a small physician practice. Do not include sensitive health information.
Practice Profile
Practice Name
*
Main Contact Name
*
Role / Title
*
Contact Email
*
example@example.com
Number of Providers / Staff
*
Security Assessment
Current security policy maturity
*
Ad hoc
1
2
3
4
Fully documented
5
1 is Ad hoc, 5 is Fully documented
Main electronic record or practice system type
*
Please Select
Cloud-based EHR
On-premise EHR
Hybrid system
Practice management system only
Paper-based with limited electronic tools
Other
Safeguard status by area
*
Rows
In place
Partially in place
Not in place
Access control
1
2
3
Device security
4
5
6
Backups
7
8
9
Staff training
10
11
12
Risks and Follow-Up
Most urgent security concern
*
Unauthorized access
Lost or stolen device
Phishing or suspicious email
Improper access to records
Incomplete safeguards
Other
Main risk notes or observations
Target follow-up or review date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional comments
Submit Assessment
Should be Empty: