Healthcare Mobile Device HIPAA Compliance Attestation Form

Employee Information

Full Name Work Email Department Mobile Device Make/Model Operating System Device Serial Number

Compliance Checklist

Device encryption is enabled Auto-lock with password or biometric is enabled Device software updates are kept current Device has anti-malware/anti-virus protection, if available No Personal Health Information (PHI) is stored on the device outside of secured applications I agree to promptly report loss/theft of device to IT/security team

Attestation

I attest that the information provided above is accurate, and I understand my responsibilities to safeguard PHI on my mobile device in compliance with HIPAA policies.

Signature

Date