Sentinel Compliance Evaluation — Practice Intake Form

🏥 Practice Information

Practice Name *

Practice Owner / Decision Maker *

Office Manager

Phone *

Best Email *

Practice Address

Practice Specialty

Number of Locations

Years in Practice

📦 Please Have Ready for the Visit

Having these items available will save time and help us give you a more accurate evaluation. Don't worry if you can't find everything — that itself is useful information.

📄

Policy Manual or Employee HandbookAny existing written policies — HIPAA, safety, HR. Even if outdated.

👤

Current Employee ListName and job title for each team member.

🤝

Vendor / Software ListEvery software, service, or vendor that handles or has access to patient data.

🎓

Training RecordsAny certificates or records showing staff completed HIPAA or OSHA training.

🗂️

Prior Audit or Inspection LettersIf you've had any regulatory contact, please have those documents available.

📁

Personnel Files (sample)One or two employee files to check for signed acknowledgments and confidentiality agreements.

✅ I Confirm the Following

I understand this is a free evaluationThere is no obligation to engage Sentinel's services after the visit.

I will have someone available for 60–90 minutesThe evaluation requires access to the office and a knowledgeable staff member.

Information shared will be kept confidentialSentinel does not share practice information with third parties.

Anything else we should know before we arrive?

✅

You're All Set!

Your intake form has been submitted to Kevin at Sentinel Compliance Command. He will be in touch within 24 hours to schedule your on-site evaluation. You can log back into your portal at any time to check your status.

Your Submission Summary

WHAT HAPPENS NEXT

Kevin reviews your intake form and schedules your on-site evaluation within the week.

Kevin visits your practice for a 60–90 minute compliance walkthrough — no disruption to patient care.

Within 48 hours of the evaluation, you receive a scored Compliance Evaluation Report. Your live compliance dashboard is activated in this portal.

You decide whether to move forward with Sentinel — no pressure, no obligation.