Form Fa-35 Electronic Transaction Agreement For Service Centers Page 2

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provides sufficient security measures to be able to associate the transaction with an individual submitting the
transaction.
The Service Center will not disclose, lend, re-sell or otherwise transfer access or data to an entity other than
a health care provider for the purposes of treatment, payment or health care operations as defined by
HIPAA.
The Service Center will not store information received on behalf of a request by a provider except to the
extent that conformation of delivery is necessary.
The Service Center is prohibited from any and all automated extraction of predictive information from data.
The Service Center will only process inquiries in the context of immediate treatment, payment or health care
operations; no en mass inquiries of eligibility data will be processed.
The Service Center will not process or store Protected Health Information as defined by HIPAA or conduct
electronic transactions involving DHCFP data from outside the geographic limits of the United States.
Penalties
DHCFP may monitor eligibility inquiries or other data transfers. Service Centers demonstrating behavior that
suggests improper use of data (e.g., high inquiry error rate or high ratio of eligibility inquiries to claims
submitted) may be suspended, put on a corrective action plan, or referred for investigation. Criminal
penalties may be imposed under HIPAA and the False Claims Act, 31 U.S. C. 3729-3733 and 18 U.S.C.
1001.
Term and Termination
This agreement will become effective when executed by both parties and may be amended only in writing,
similarly executed.
This agreement may be terminated with thirty (30) days written notice by either party. HPE or DHCFP may
immediately terminate this agreement if the Service Center fails to comply with or violates a material
provision of this agreement.
_____________________________________________
_________________________________________
Signature of authorized Service Center agent
Title of authorized agent
____________________________
Date signed
For HPE Use Only
Service Center Code: _______________________________________
Signature of EDI Coordinator: _______________________________________ Date: ___________________
02/23/2015
FA-35
(pv 01/15/2013)
2/2

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