Business Associate Agreement Page 3

Download a blank fillable Business Associate Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Business Associate Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

h. “Protected Health Information” means Individually Identifiable Health Information
that is transmitted by electronic media; maintained in any medium described in the
definition of the term electronic media in the HIPAA Regulations; or transmitted or
maintained in any other form or medium.
Protected Health Information excludes
Individually Identifiable Health Information in education records covered by the Family
Educational Right and Privacy Act, as amended, 20 U.S.C. § 1232g, and records
described at 20 U.S.C. § 1232g(a)(4)(B)(iv).
i. “Security Incident” means the attempted or successful unauthorized access, use,
disclosure, modification, or destruction of information or interference with system
operations in an information system.
2.
Status of Parties. BA hereby acknowledges and agrees that CE is a Covered Entity and
that BA is a Business Associate of CE.
3.
Permitted Uses and Disclosures.
a. Performance of Services. BA may use and disclose PHI in connection with the
performance of the services [listed in Exhibit A attached to this Agreement] [provided in
Agreement] if such use or disclosure of PHI would not violate HIPAA or the
HIPAA Regulations if done by Covered Entity or such use or disclosure is expressly
permitted under Section 3.b. or 3.c. of this Agreement.
b. Proper Management and Administration.
BA may use PHI for the proper
management and administration of BA in connection with the performance of services
described in Exhibit A attached to this Agreement and as permitted by this Agreement.
BA may disclose CE’s PHI for such proper management and administration of BA only
with the prior consent of CE. Any such disclosure of PHI shall only be made if BA
obtains reasonable assurances from the person to whom the PHI is disclosed that: (1) the
PHI will be held confidentially and used or further disclosed only as required by law or
for the purpose for which it was disclosed to the person; and (2) BA will be notified by
such person of any instances of which it becomes aware in which the confidentiality of
the PHI has been breached.
c. [INCLUDE ONLY IF BA WILL BE DOING DATA AGGREGATION FOR CE;
OTHERWISE DELETE] [Except as otherwise limited in this Agreement, BA may
use PHI to provide Data Aggregation services to CE as permitted by 45 C.F.R. §
164.504(e)(2)(i)(B). Data Aggregation services involve the combining by BA of (a)
PHI with (b) Protected Health Information received by BA in its capacity as a
business associate of another Covered Entity, to permit data analyses that relate to
the health care operations of the respective Covered Entities.]
-3-
9100767.3

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 8