SECTION 1 — ORGANIZATION IDENTIFICATION

Legal Business Name

DBA (if applicable)

Facility Type (Check One)

Street Address

City

State

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)

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)

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)

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

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.