Healthcare AI Compliance Infrastructure
Pre-Build Qualification Form
This form is required prior to initiating Regulatory Mapping (Phase 1).
Completion does not constitute legal advice or regulatory approval.
SECTION 1 — ORGANIZATION IDENTIFICATION
Legal Business Name
DBA (if applicable)
Facility Type (Check One)
Family Medical Practice
Urgent Care Center
Ambulatory Surgical Center
Behavioral Health / Substance Use Treatment
Long-Term Care Facility
Federally Qualified Health Center (FQHC)
Multi-Specialty Clinic
Street Address
City
State
Country
Country
Postal Code
Primary Contact Name
Title
Phone
*
Email
*
Single Location or Multi-Location?
Single Location
Multi-Location
SECTION 2 — REGULATORY JURISDICTION CONFIRMATION
Does the organization accept
Medicare
Medicaid (TennCare)
Commercial Insurance
Self-Pay Only
Primary Licensing Authority
Tennessee Department of Health
Tennessee Department of Mental Health & Substance Abuse Services
CMS (Conditions for Coverage)
HRSA (FQHC)
Have you experienced within the last 3 years
CMS Audit
HIPAA Complaint/Investigation
OSHA Inspection
State Licensing Review
None
Are there active corrective action plans (CAPs)?
Yes
No
SECTION 3 — ORGANIZATIONAL STRUCTURE & DEPARTMENTS
Total Employee Count:
Department Breakdown
Front Desk / Intake
Clinical Providers (MD/DO/NP/PA)
Nursing / MA Staff
Billing & Revenue Cycle
Compliance / Risk
HR
IT / EHR Administration
Executive Leadership
Is there a designated Compliance Officer?
Yes
No
Payroll Handling
Internal
Third-Party Vendor
SECTION 4 — DATA SENSITIVITY & RISK CLASSIFICATION
Data Types Handled (Check all that apply)
Protected Health Information (PHI)
Behavioral Health Records
Substance Use Treatment Records (42 CFR Part 2)
Minor Patient Records
Biometric Data
Payment Card / Financial Data
Government Contract Data
Access Segmentation
Is PHI access restricted by role?
Yes
No
Is payroll access restricted to finance only?
Yes
No
Are disciplinary records protected from general staff?
Yes
No
Has the organization experienced a data breach?
Yes
No
Consultant Risk Assessment
Low
Medium
High
Extreme
SECTION 5 — POLICY & DOCUMENTATION STATUS
Written Policies in Place
HIPAA Privacy & Security
Yes
No
Incident Reporting Protocol
Yes
No
OSHA & Workplace Safety
Yes
No
Medication Management
Yes
No
Billing & Coding Compliance
Yes
No
HR & Labor Policies
Yes
No
Minor Consent Procedures
Yes
No
Data Breach Response Plan
Yes
No
Are policies reviewed annually?
Yes
No
SECTION 6 — AI INFRASTRUCTURE OBJECTIVE
Purpose of AI Compliance Infrastructure (Select All)
Regulatory Mapping Support
HIPAA Advisory Structuring
Incident Documentation Control
HR & Payroll Governance
Audit Readiness
CMS Survey Preparation
Executive Oversight Dashboard
System Scope
Internal Use Only
Multi-Location Governance
Executive-Level Restricted Infrastructure
Desired Security Tier
Tier 1 — Advisory Segmentation
Tier 2 — Department Code Authentication
Tier 3 — Enterprise Silent Governance Model
SECTION 7 — SENTRIX CONSULTANT USE ONLY
Estimated Build Tier
$12K–$18K (Medium Risk)
$18K–$25K (High Risk)
$25K–$50K+ (Extreme Risk)
Projected Monthly Retainer
CERTIFICATION
I certify that the information provided above is accurate and complete to the best of my knowledge.
Authorized Representative Name
Signature:
Clear
Date
Submit