9-Data Sharing Assessment v2.docx
DOCX document 29 KB Posted
- Solicitation number
- 25-06890
- 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 serves as a comprehensive intake document designed to identify and document all data sharing relationships between IEHP and external entities, including vendors, subcontractors, and offshore resources. The assessment captures critical contact information for both IEHP departments and third-party providers, establishes service start and end dates, and requires detailed explanations of service descriptions and data transmission methods.
The form systematically inventories all categories of sensitive information exchanged with vendors, including personally identifiable information (PII) such as names, addresses, dates of birth, Social Security numbers, member health plan IDs, and financial account details, as well as protected health information (PHI) encompassing medical diagnoses, treatment records, prescriptions, healthcare claims, and related clinical data. The assessment requires vendors to disclose whether they utilize offshore resources, subcontractors, or global workforces and to identify the specific countries and services involved. Additionally, the form requires documentation of the approximate number of individuals whose information will be accessed, viewed, used, disclosed, or handled by the vendor, establishing a foundational data governance and risk management mechanism for IEHP's vendor relationships.
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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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