Business Associate Agreement printable pdf download

THIS IS A TEMPLATE ONLY. CERTAIN STATES MAY NOT

PERMIT THE TYPES OF ACTIVITIES ALLOWED HEREUNDER RELATING

TO PROTECTED HEALTH INFORMATION. THUS THIS AGREEMENT MAY

NEED TO BE MODIFIED IN ORDER TO COMPLY WITH MORE

RESTRICTIVE, APPLICABLE STATE LAW.

Where indicated below, Option 1 provisions are for use when this business

associate agreement will be an amendment, addendum or rider to an existing services

agreement and Option 2 provisions are for use when this business associate agreement will be

the only written agreement between the parties regarding the business associate services to be

provided. All other provisions of the agreement can be included in both options.

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (this “B.A. Agreement”), dated

______________, 200_, is entered into by and between _________________, with an

address at _______________ (the “Business Associate”) and ________________, with an

address at _____________________ (the “Covered Entity”) (each a “Party” and

collectively the “Parties”).

[Required: Choose one option as appropriate.]

[OPTION 1 The Parties have entered into a prior agreement entitled

_________ dated _________ (the “Underlying Agreement”). Performance of the

Underlying Agreement may involve Protected Health Information (as defined in 45

C.F.R. § 164.501) that is subject to the federal privacy regulations issued pursuant to

the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and

codified at 45 C.F.R. parts 160 and 164 (the “Privacy Rule”). The purpose of this B.A.

Agreement is to amend the Underlying Agreement to the extent and only to the extent

necessary to allow for Covered Entity’s compliance with the Privacy Rule with respect

to this Underlying Agreement.]

[OPTION 2 The Parties have agreed that Business Associate will

perform the following functions and provide the following services for or on behalf of

the Covered Entity: __________ [list functions or services which are permitted

by the Privacy Rule and require a Business Associate Agreement under

the Privacy Rule (see 45 C.F.R. § 164.501)]. Performance of such functions and

provision of such services by the Business Associate may involve Protected Health

Information (as defined in 45 C.F.R. § 164.501) that is subject to the federal privacy

regulations issued pursuant to the Health Insurance Portability and Accountability

Act of 1996 (“HIPAA”) and codified at 45 C.F.R. parts 160 and 164 (the “Privacy Rule”).

The purpose of this B.A. Agreement is to set forth the obligations of the Parties with

respect to such Protected Health Information.]

The Parties hereby agrees as follows:

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Business Associate Agreement