9-Data Sharing Assessment v2.docx
DOCX document 29 KB Posted
- Attached to
- Consent and Preference Management Software
- Solicitation number
- 25-06921
- Issued by
- San Bernardino County, California
About this file
This is a Data Sharing Assessment Form for Inland Empire Health Plan (IEHP), a California health plan organization, used to evaluate third-party vendors and service providers handling sensitive information. The form requests detailed information about vendor services, data transmission methods, use of offshore resources or subcontractors, and the specific types of information that will be accessed or maintained. The assessment identifies two primary data categories: Personally Identifiable Information (PII) including names, addresses, dates of birth, contact information, Social Security numbers, member health plan IDs, financial account details, and biometric identifiers; and Medical or Behavioral Health Information including diagnoses, treatment records, prescriptions, healthcare payment information, and ancillary service data. The form applies to information regarding IEHP employees, team members, and health plan members, with vendors required to specify the approximate number of individuals whose information will be viewed, used, disclosed, or handled.
The form serves as a due diligence and compliance mechanism for IEHP to assess data security practices and regulatory requirements related to Health Insurance Portability and Accountability Act (HIPAA) and other privacy protections. Vendors must complete all sections including company contact information, estimated service dates, detailed descriptions of services provided, methods of sensitive information transmission and maintenance, identification of any global workforce components, and quantification of affected individuals. This assessment form is fundamental to the broader Consent and Preference Management Software procurement effort outlined in California's related RFP, establishing baseline requirements for vendor selection and ongoing monitoring of data handling practices.
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Text version
Section A: IEHP Contact Information
IEHP Department(s) Using Service or Vendor
IEHP Point of Contact Name
IEHP Point of Contact Title
IEHP Point of Contact Extension
Section B: 3rd Party / Vendor Contact Information
Company Name:
Company Address:
Company Web Site:
Primary Contact Name:
Primary Contact phone number:
Primary Contact email address:
Estimated Start Date
Estimated End Date
Section C: Services Provided to IEHP (Please give detailed explanation)
Section D: How is/ will sensitive information be transmitted, received, created/ maintained between IEHP & 3rd Party/ Vendor? (Please give detailed explanation)
Section E: Will 3rd party/ Vendor use offshore resources/ subcontractor(s)/ have a global workforce? If Yes, please explain in detail regarding country/ countries & services that require this.
IEHP Da t a Sha r ing Ass e ssment F o r m
Section F: Identify the types of information that will be received, viewed, used, disclosed or handled by vendor
Personally Identifiable Information (PII)
WHO IS THE DATA ABOUT?
| IEHP |
| IEHP Team |
| IEHP |
| Members |
| Members |
| Providers |
Full first name
Full last name
Complete addresses smaller than a state
Date of Birth
Phone numbers
Fax numbers
Email addresses
Social Security numbers
Member health plan ID number
Banking or Financial accounts
Driver’s License numbers
Vehicle identifiers and serial numbers, including license plate numbers
Individual's Website URLs
Internet Protocol (IP) address numbers
Biometric identifiers, including finger, retinal and voice prints
Full face photographic images
Any other unique number characteristic or code directly related to an individual not listed above
Medical or Behavioral Health Information
WHO IS THE DATA ABOUT?
IEHP
IEHP Team Members
Members
Medical information including diagnosis, admission \ discharge dates, healthcare treatment, medical history, medical records, etc.
Prescriptions
Healthcare payment information including claims, bills, receipts and explanation of benefits
Ancillary services including x-rays and labs
Data or information related to the provision of health care to an individual not listed above
Section G: Number of persons information being shared Approximate number of persons whose information will be viewed, used, disclosed or handled
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