BUSINESS ASSOCIATE AGREEMENT

Size: px
Start display at page:

Download "BUSINESS ASSOCIATE AGREEMENT"

Transcription

1 BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) is entered into this 22 nd day of September, 2014 ( Effective Date ), by and between Customer_Name with a place of business at Address_Line1, Address_Line2, Address_Line3, Address_Line4, City, State, Postal_Code and COLLEGE OF AMERICAN PATHOLOGISTS ( CAP ) with its principal place of business at 325 Waukegan Road, Northfield, IL Individually, the CAP and Customer_Name shall be referred to as Party, and together, the CAP and Customer_Name shall be referred to as Parties. WHEREAS CAP (the Business Associate ) provides laboratory accreditation, inspection, and related services to Customer_Name (the Covered Entity ); WHEREAS the disclosure of certain PHI shall be regulated by the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009 ( HITECH Act ), and their implementing regulations at 45 C.F.R. Parts 160, 162 and 164 ( Regulations ); WHEREAS Covered Entity may from time to time disclose to Business Associate certain PHI that is subject to protection under HIPAA and the HITECH Act, and the Regulations; WHEREAS to the extent applicable, Business Associate and Covered Entity desire to comply with the applicable provisions of HIPAA, the HITECH Act, and the Regulations; and NOW THEREFORE, for and in consideration of the premises and other good and valuable consideration the receipt and sufficiency of which is hereby acknowledged, it is agreed by and between the Parties hereto that the terms listed below provide a full statement of their responsibilities under this Agreement. I. Definitions Terms used herein but not otherwise defined in this Agreement shall have the same meaning as the meaning ascribed to those terms in HIPAA, the HITECH Act, and the Regulations. (a) Breach of Unsecured PHI shall have the meaning set forth in 45 C.F.R (b) Business Associate shall have the same meaning as the term Business Associate under 45 C.F.R , and in reference to the Party to this Agreement, shall mean CAP. Business Associate is limited to being construed as an independent contracting party and no other relationship shall be construed to exist between Business Associate and Covered Entity under this Agreement. Page 1 of 8

2 (c) Covered Entity shall have the same meaning as the term Covered Entity under 45 C.F.R , and in reference to the Party to this Agreement, shall mean Customer_Name. (d) HIPAA shall mean the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. 1320d et seq. (e) HITECH Act shall mean the Health Information Technology for Economic and Clinical Health Act of 2009, as codified at 42 U.S.C et seq. (f) Individual shall have the same meaning as the term Individual in 45 C.F.R , and shall include a person who qualifies as a personal representative as set forth at 45 C.F.R (g). (g) PHI shall have the same meaning as the protected health information as set forth at 45 C.F.R and includes genetic information as set forth in the Genetic Information Nondiscrimination Act of PHI is limited to the information created, received, maintained or transmitted by Business Associate on behalf of or from Covered Entity. (h) Privacy Rule shall mean the Standards for Privacy of Individually Identifiable Health Information as set forth at 45 C.F.R. Parts 160 and 164 (Subparts A, E). (i) Regulations shall mean any current and future regulations promulgated under either HIPAA or the HITECH Act, including but not limited those set forth at 45 C.F.R. Parts 160, 162 and 164. (j) Required by Law shall have the same meaning as the term required by law as set forth at 45 C.F.R (k) Secretary shall mean the Secretary of the United States Department of Health and Human Services or his or her designee. (l) Security Incident shall mean the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system as set forth at 45 C.F.R (m) Security Rule shall mean the portion of the Regulations regarding security of information technology in order to prevent unlawful use or disclosure of PHI as set forth at 45 C.F.R. Parts 160, 162, 164 (Subparts A and C). (n) Service Agreement shall mean any executed contract, agreement, memorandum of understanding, application for services, or similar legally binding agreement for any services provided by the Business Associate to the Covered Entity which would pertain to the subject matter of this Agreement. Page 2 of 8

3 (o) Standards for Privacy of Individually Identifiable Health Information shall mean the portion of the Regulations set forth at 45 C.F.R. 160, 164 (Subparts A, E). (p) Unsecured PHI shall mean PHI not secured by a technology standard that renders the information unusable, unreadable, or indecipherable according to standards developed by an organization that is accredited by the American National Standards Institute as set forth at 45 C.F.R II. Obligations and Activities of the Business Associate To the extent applicable, Business Associate agrees to: (a) not use or disclose PHI other than as permitted or required to perform services for the Covered Entity (the Services ), as permitted or required by this Agreement or as required by law; (b) use appropriate administrative, physical, and technical safeguards, and comply with Subpart C of 45 C.F.R. Part 164, with respect to electronic PHI, to prevent use or disclosure of PHI other than as provided for by the Agreement; (c) report to Covered Entity any use or disclosure of PHI not permitted by the Agreement of which it becomes aware, including a Breach of Unsecured PHI as required under 45 C.F.R , and any Security Incident of which it becomes aware. The Business Associate agrees to promptly notify without unreasonable delay the Covered Entity of any Breach of Unsecured PHI after the Breach of Unsecured PHI is discovered by the Business Associate in accord with 45 C.F.R ; (d) in accordance with 45 C.F.R (e)(1)(ii) and 45 C.F.R (b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of the Business Associate agree to restrictions, conditions, and requirements at least as stringent as those that apply to the Business Associate with respect to such information. Business Associate shall enter into agreements with any subcontractors, and the terms of such agreements shall incorporate the applicable requirements of, and otherwise comply with, the Regulations; (e) make available PHI in a Designated Record Set to the Covered Entity as necessary to satisfy Covered Entity s obligations under 45 C.F.R The Business Associate shall promptly furnish PHI in a Designated Record Set to the Covered Entity upon receiving a request to furnish such PHI to the Covered Entity. The Parties agree and acknowledge that it is the Covered Entity s responsibility to respond to all requests for access. Any request under 45 C.F.R from an Individual made directly to Business Associate will be referred to Covered Entity; (f) make any amendment(s) to PHI in a Designated Record Set as directed or agreed to by the Covered Entity pursuant to 45 C.F.R or take other measures as Page 3 of 8

4 necessary to satisfy Covered Entity s obligations under 45 C.F.R The Parties agree and acknowledge that it is Covered Entity s responsibility to respond to all requests for amendments. Any request under 45 C.F.R from an Individual made directly to Business Associate will be referred to Covered Entity; (g) to the extent Business Associate maintains PHI in a Designated Record Set, make available the information required to provide an accounting of disclosures to the Covered Entity as necessary for the Covered Entity to satisfy Covered Entity s obligations under 45 C.F.R ; (h) to the extent the Business Associate is to carry out one or more of Covered Entity's obligation(s) under 45 C.F.R. Part 164 (Subpart E), comply with the requirements of 45 C.F.R. Part 164 (Subpart E) that apply to the Covered Entity in the performance of such obligation(s); and (i) make its internal practices, books, and records available to the Secretary for purposes of determining Covered Entity s compliance with HIPAA, the HITECH Act, and the Regulations. III. Permitted Uses and Disclosures by Business Associate (a) Business Associate may use and disclose PHI as permitted or required to perform Services for the Covered Entity as permitted or required by this Agreement, and as Required by Law. (b) Business Associate may use PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate. Business Associate may disclose PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate, provided that: 1. disclosures are Required By Law, or 2. Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person, and 3. the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached. (c) Business Associate may, but is not required to, use PHI to provide Data Aggregation Services to Covered Entity as permitted by 45 C.F.R (e)(2)(i)(B). (d) Business Associate may use PHI to report violations of law to appropriate federal and state authorities, consistent with 45 C.F.R (j)(1). Page 4 of 8

5 (e) Business Associate agrees to limit, to the extent practicable and except as permitted by 45 C.F.R (b)(2), its use, disclosure and requests of PHI under the Agreement to a limited data set (as defined in 45 C.F.R (e)(2)) or, if needed by Business Associate to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request. (f) Business Associate may not use or disclose PHI in a manner that would violate 45 C.F.R. Part 164 (Subpart E) if such use or disclosure were to be done by Covered Entity, except as permitted by 45 C.F.R (e)(4). (g) Business Associate may use PHI to create de-identified information or a limited data set consistent with the standards set forth at 45 C.F.R (h) Business Associate shall not sell PHI or use or disclose PHI for purposes of marketing, except as otherwise permitted by HIPAA, the HITECH Act, or the Regulations. IV. Obligations and Activities of the Covered Entity (a) Covered Entity shall notify Business Associate of any limitation(s) in the notice of privacy practices of Covered Entity, in accordance with 45 C.F.R , to the extent that such limitation may affect Business Associate s use or disclosure of PHI. (b) Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose PHI, to the extent that such changes may affect Business Associate s use or disclosure of PHI. (c) Covered Entity shall notify Business Associate of any restrictions on the use or disclosure of PHI that Covered Entity has agreed to in accordance with 45 C.F.R , to the extent that such changes may affect Business Associate s uses or disclosures of PHI. (d) Covered Entity shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under 45 C.F.R. Part 164 (Subpart E) if done by Covered Entity except as permitted by 45 C.F.R (e)(4) of this Agreement. (e) Covered Entity agrees to limit, to the extent practicable and except as permitted by 45 C.F.R (b)(2), its use, disclosure and requests of PHI under the Agreement to deidentified information (as defined in 45 C.F.R (b)(2)) if requested by Business Associate, or a limited data set (as defined in 45 C.F.R (e)(2) or, if needed by Covered Entity, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request. V. Term and Termination (a) Termination for Cause. Upon either Party s knowledge of a material breach by the other Party, the non-breaching Party shall: Page 5 of 8

6 1. provide an opportunity for the breaching Party to cure the breach within 30 (thirty) days but shall terminate this Agreement (and any underlying agreement) if the breaching Party does not cure the breach; 2. if cure is not possible, immediately terminate this Agreement and any underlying agreement; or 3. if neither termination nor cure are feasible, may report the breach to the Secretary. (b) Term. The Term of this Agreement shall be effective as of the Effective Date set forth above and shall terminate on the date either Party terminates for cause as authorized in paragraph (a) of this Section V, or the date any underlying Service Agreement terminates, whichever first occurs. (c) Obligations of Business Associate Upon Termination. Upon termination of this Agreement for any reason, Business Associate, with respect to PHI received from Covered Entity, or created, received, maintained, or transmitted by Business Associate on behalf of Covered Entity, shall: 1. Retain that PHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities; 2. If feasible, return to Covered Entity or destroy the remaining PHI that the Business Associate still maintains in any form; 3. Continue to use appropriate safeguards and comply with 45 C.F.R. Part 164 (Subpart C) with respect to electronic PHI to prevent use or disclosure of the PHI, other than as provided for in this Section V, for as long as Business Associate retains the PHI; 4. Not use or disclose the PHI retained by Business Associate other than for the purposes for which such PHI was retained and subject to the same conditions set out at 45 C.F.R (e)(4) which applied prior to termination; and 5. Return to Covered Entity or destroy the PHI retained by Business Associate when it is no longer needed by Business Associate for its proper management and administration or to carry out its legal responsibilities. (d) Survival. The obligations of Business Associate under this Section V(c) shall survive the termination of this Agreement. VI. Notices All notices, requests, consents and other communications hereunder will be: 1. in writing and addressed to the receiving Party s address set forth above or to such other address as a Party may designate by notice hereunder, Page 6 of 8

7 2. either delivered by hand, made by facsimile transmission, sent by overnight courier, or sent by registered/certified mail, return receipt requested, postage prepaid to the appropriate contacts. VII. Miscellaneous (a) Entire Agreement. This Agreement sets forth the entire understanding of the Parties with respect to the subject matter set forth herein and supersedes all prior Agreements, arrangements and communications, whether oral or written, pertaining to the subject matter hereof. (b) Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance by Covered Entity and Business Associate with HIPAA, the HITECH Act, and the Regulations. (c) Third Party Beneficiaries. This Agreement is not intended to benefit any person or entity not a party to this Agreement. (d) Amendment. The Parties agree to take reasonable step to negotiate an amendment to this Agreement from time to time as is necessary to comply with the applicable requirements of HIPAA, the HITECH Act, and the Regulations. [Signatures follow] Page 7 of 8

8 IN WITNESS WHEREOF, the Parties hereto have signed this Agreement the date and year first written above by the duly authorized representative. Facsimile or electronically scanned transmission of an executed copy of this Agreement or any amendments thereto shall be accepted as evidence of a party s execution of the Agreement or amendment. This Agreement may be executed in multiple counterparts, each of which shall be deemed to be an original. COLLEGE OF AMERICAN PATHOLOGISTS By: signature printed Title: Date: Customer_Name By: signature printed Title: Date: ACTIVE Page 8 of 8

HIPAA Information. Who does HIPAA apply to? What are Sync.com s responsibilities? What is a Business Associate?

HIPAA Information. Who does HIPAA apply to? What are Sync.com s responsibilities? What is a Business Associate? HIPAA Information Who does HIPAA apply to? HIPAA applies to all Covered Entities (entities that collect, access, use and/or disclose Protected Health Data (PHI) and are subject to HIPAA regulations). What

More information

SUBCONTRACTOR BUSINESS ASSOCIATE AGREEMENT

SUBCONTRACTOR BUSINESS ASSOCIATE AGREEMENT SUBCONTRACTOR BUSINESS ASSOCIATE AGREEMENT (Revised on March 1, 2016) THIS HIPAA SUBCONTRACTOR BUSINESS ASSOCIATE AGREEMENT (the BAA ) is entered into on (the Effective Date ), by and between ( EMR ),

More information

Business Associate Agreement

Business Associate Agreement Business Associate Agreement This Business Associate Agreement (this Agreement ) is entered into on the Effective Date of the Azalea Health Software as a Service Agreement and/or Billing Service Provider

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This Agreement, dated as of, 2018 ("Agreement"), by and between, on its own behalf and on behalf of all entities controlling, under common control with or controlled

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT (this Agreement ) is by and between You, the Covered Entity ( Covered Entity ), and Paubox, Inc. ( Business Associate ). This BAA is effective

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( Agreement ) by and between (hereinafter known as Covered Entity ) and Office Ally, Inc., a clearinghouse Covered Entity under HIPAA, providing

More information

ACGME BUSINESS ASSOCIATE AGREEMENT

ACGME BUSINESS ASSOCIATE AGREEMENT ACGME Business Associate Agreement Template Clinical Site 8/1/2014 Institution Number (Insert name of sponsoring institution, co-sponsor, participating institution or clinical site and institution number

More information

PATTERSON MEDICAL SUPPLY, INC. HIPAA BUSINESS ASSOCIATE AGREEMENT WITH CUSTOMERS

PATTERSON MEDICAL SUPPLY, INC. HIPAA BUSINESS ASSOCIATE AGREEMENT WITH CUSTOMERS PATTERSON MEDICAL SUPPLY, INC. HIPAA BUSINESS ASSOCIATE AGREEMENT WITH CUSTOMERS This HIPAA Business Associate Agreement ( BA Agreement ), effective as of the last date written on the signature page attached

More information

BUSINESS ASSOCIATE AGREEMENT W I T N E S S E T H:

BUSINESS ASSOCIATE AGREEMENT W I T N E S S E T H: BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( this Agreement ) is made and entered into as of this day of 2015, by and between TIDEWELL HOSPICE, INC., a Florida not-for-profit corporation,

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATES AND SUBCONTRACTORS

HIPAA BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATES AND SUBCONTRACTORS HIPAA BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATES AND SUBCONTRACTORS This HIPAA Business Associate Agreement ( BAA ) is entered into on this day of, 20 ( Effective Date ), by and between Allscripts

More information

Business Associate Agreement

Business Associate Agreement This Business Associate Agreement Is Related To and a Part of the Following Underlying Agreement: Effective Date of Underlying Agreement: Vendor: Business Associate Agreement This Business Associate Agreement

More information

ARTICLE 1. Terms { ;1}

ARTICLE 1. Terms { ;1} The parties agree that the following terms and conditions apply to the performance of their obligations under the Service Contract into which this Exhibit is being incorporated. Contractor is providing

More information

Business Associate Agreement

Business Associate Agreement Business Associate Agreement THIS BUSINESS ASSOCIATE AGREEMENT (this Agreement ) is effective by and between CRESTPOINT HEALTH INSURANCE COMPANY, on behalf of itself and its affiliates (collectively, Covered

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Agreement is by and between The Health Plan ( Plan ) and Priority Health Managed Benefits, Inc., a Michigan Third Party Administrator ( Business Associate

More information

Interpreters Associates Inc. Division of Intérpretes Brasil

Interpreters Associates Inc. Division of Intérpretes Brasil Interpreters Associates Inc. Division of Intérpretes Brasil Adherence to HIPAA Agreement Exhibit B INDEPENDENT CONTRACTOR PRIVACY AND SECURITY PROTECTIONS RECITALS The purpose of this Agreement is to enable

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( Agreement ), is between Birch Family Services, Inc., a New York not-for-profit corporation ( Covered Entity ) and ( Business Associate

More information

HIPAA Business Associate Agreement Passport to Languages

HIPAA Business Associate Agreement Passport to Languages HIPAA Business Associate Agreement Passport to Languages This Agreement, dated as of, ( Agreement ), is entered into by and between Passport to Languages ( Business Associate ) and. ( Covered Entity ).

More information

Business Associate Agreement For Protected Healthcare Information

Business Associate Agreement For Protected Healthcare Information Business Associate Agreement For Protected Healthcare Information This Business Associate Agreement ( Agreement ) is entered into this 24th day of February 2017, between PRACTICE-WEB, Inc., a California

More information

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT BUSINESS ASSOCIATE TERMS AND CONDITIONS

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT BUSINESS ASSOCIATE TERMS AND CONDITIONS COVERYS RRG, INC. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT BUSINESS ASSOCIATE TERMS AND CONDITIONS WHEREAS, the Administrative Simplification section of the Health Insurance Portability and

More information

FACT Business Associate Agreement

FACT Business Associate Agreement Policy Document #: 2.1.003 Revision: 3 Valid Date: 27June2012 Page 1 of 2 Effective Date: 27Jun2012 FACT Business Associate Agreement 1.0 Purpose The purpose of this document is to establish terms for

More information

Business Associate Agreement Health Insurance Portability and Accountability Act (HIPAA)

Business Associate Agreement Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreement Health Insurance Portability and Accountability Act (HIPAA) This Business Associate Agreement (the Agreement ) is made and entered into by and between Washington Dental Service

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (this Agreement ) is made effective as of the of, (the Effective Date ), by and between day hereafter referred to as ( Business Associate

More information

ARTICLE 1 DEFINITIONS

ARTICLE 1 DEFINITIONS [GPM Note: This Template Data Use Agreement is to be used when a covered entity seeks to disclose a limited set of PHI to another entity for research, public health, and/or health care operations purposes.

More information

IHDE BUSINESS ASSOCIATE AGREEMENT (BAA)

IHDE BUSINESS ASSOCIATE AGREEMENT (BAA) IHDE BUSINESS ASSOCIATE AGREEMENT (BAA) This Business Associate Agreement (BAA) is entered into by and between the Covered Entity aka. Data Provider/User, (please enter name of organization) and the Business

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (the Agreement ) is entered into this day of, 20, by and between ( Covered Entity ) and the University of Maine System, acting through the

More information

RECITALS. In consideration of the mutual promises below and the exchange of information pursuant to this BAA, the Parties agree as follows:

RECITALS. In consideration of the mutual promises below and the exchange of information pursuant to this BAA, the Parties agree as follows: This Business Associate Agreement ( BAA ) is entered into by and between NORCAL Mutual Insurance Company ( NORCAL ) and Insured/Applicant ( Covered Entity ) and is effective as of September 23 rd, 2013

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (the Agreement ) is entered into this day of, 20, by and between the University of Maine System ( University ), and ( Business Associate ).

More information

HIPAA and ProAssurance

HIPAA and ProAssurance HIPAA and ProAssurance The ProAssurance Companies, along with our legal counsel, have reviewed the Health Insurance Portability And Accountability Act of 1996, and its implementing regulations (collectively,

More information

NETWORK PARTICIPATION AGREEMENT

NETWORK PARTICIPATION AGREEMENT NETWORK PARTICIPATION AGREEMENT THIS NETWORK PARTICIPATION AGREEMENT ( Agreement ) is entered into on the date(s) indicated below, by and between the undersigned physician (hereinafter Physician ; and

More information

BUSINESS ASSOCIATE AGREEMENT Between THE NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS and

BUSINESS ASSOCIATE AGREEMENT Between THE NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS and BUSINESS ASSOCIATE AGREEMENT Between THE NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS and WHEREAS, Dallas County, Tarrant County, Denton County, Parker County, the North Texas Tollway Authority have created

More information

BUSINESS ASSOCIATE AGREEMENT (for use when there is no written agreement with the business associate)

BUSINESS ASSOCIATE AGREEMENT (for use when there is no written agreement with the business associate) BUSINESS ASSOCIATE AGREEMENT (for use when there is no written agreement with the business associate) This HIPAA Business Associate Agreement ( Agreement ) is entered into this day of, 20, by and between

More information

SUBCONTRACTOR BUSINESS ASSOCIATE ADDENDUM

SUBCONTRACTOR BUSINESS ASSOCIATE ADDENDUM SUBCONTRACTOR BUSINESS ASSOCIATE ADDENDUM This Subcontractor Business Associate Addendum (the Addendum ) is entered into this day of, 20, by and between the University of Maine System, acting through the

More information

COBRA Setup Fact Sheet for Oswald agent

COBRA Setup Fact Sheet for Oswald agent COBRA Setup Fact Sheet for Oswald agent NEO provides full-service administration of COBRA compliance obligations. Once set-up is complete, the employer simply notifies NEO after they commence or terminate

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT (the Agreement ) is entered into this day of, 20, by and between the University of Maine System acting through the University of ( University

More information

HIPAA ADDENDUM TO SERVICE AGREEMENT

HIPAA ADDENDUM TO SERVICE AGREEMENT HIPAA ADDENDUM TO SERVICE AGREEMENT Business Associate Trading Partner and Chain of Trust THIS AGREEMENT made this 29th day of May, 2015, between, hereafter referred to as Covered Entity, and Commercial

More information

HIPAA Business Associate Agreement

HIPAA Business Associate Agreement HIPAA Business Associate Agreement ICANotes LLC doing business at 1600 St Margarets Rd, Annapolis MD 21409 and, doing business at are parties to a Business Associate arrangement as defined under the Health

More information

TEXAS SOUTHERN UNIVERSITY HIPAA BUSINESS ASSOCIATE AGREEMENT

TEXAS SOUTHERN UNIVERSITY HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement (this BA Agreement ) is made and entered into by ( Provider ), a, located at, and Texas Southern University, an agency and institution of higher education established

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT PREVIEW VERSION ONLY This Business Associate Agreement (BAA) is made available for preview purposes only. It is indicative of the BAA that will be presented through the online user interface for acceptance

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This Agreement ( Agreement ) is entered into by and between Applications Software Technology Corporation (AST) ( Business Associate ) and Pinellas County, for and on

More information

* Corporation General Partnership Limited Partnership LLC Sole Proprietorship Non Profit Other Accounts Payable: Name

* Corporation General Partnership Limited Partnership LLC Sole Proprietorship Non Profit Other Accounts Payable: Name INVACARE CORPORATION New Customer Change of Ownership Customer Credit Application *Legal Name of Business Trade Name (DBA) *Billing Address: Shipping Address (if different): *Federal Tax ID # * # of Years

More information

Emma Eccles Jones College of Education & Human Services. Title: Business Associate Agreements

Emma Eccles Jones College of Education & Human Services. Title: Business Associate Agreements POLICY INFORMATION Document # 900 Revision # 1.0 Safeguard: Administrative Title: Business Associate Agreements Prepared by: J. Black Approved by: Dean Beth E. Foley Print Date: 8/29/2016 Date Prepared:

More information

SDM Health Insurance Portability and Accountability Act (HIPAA) Terms and Conditions For Business Associates

SDM Health Insurance Portability and Accountability Act (HIPAA) Terms and Conditions For Business Associates Policy and Procedure: SDM HIPAA Terms and Conditions for (Adapted from UPMC s HIPAA Terms and Conditions for at http://www.upmc.com/aboutupmc/supplychainmanagement/documents/terms.pdf) Effective: 03/30/2012

More information

HOW TO COMPLETE A BUSINESS ASSOCIATE AGREEMENT (BAA)

HOW TO COMPLETE A BUSINESS ASSOCIATE AGREEMENT (BAA) HOW TO COMPLETE A BUSINESS ASSOCIATE AGREEMENT (BAA) Once office has determined they would like to complete a Business Associate Agreement (BAA) with The Lash Group, Inc. dba Premier Source, please complete

More information

Business Associate Agreement RECITALS AGREEMENT

Business Associate Agreement RECITALS AGREEMENT Business Associate Agreement Read the Business Associate Agreement and sign electronically or download, print, and sign. Completed form may be uploaded to Provider Portal, faxed to Janssen CarePath at

More information

JOTFORM HIPAA BUSINESS ASSOCIATE AGREEMENT

JOTFORM HIPAA BUSINESS ASSOCIATE AGREEMENT JOTFORM HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement ( HIPAA BAA ) is made between JotForm, Inc., ( JotForm ) and {YourCompanyName} ( Covered Entity or Customer ) as an agreement

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Agreement dated as of is made by and between, on behalf of its (School/Department/Division) (hereinafter referred to as Covered Entity ) and, (hereinafter Business Associate

More information

Limited Data Set Data Use Agreement For Research

Limited Data Set Data Use Agreement For Research Limited Data Set Data Use Agreement For Research This Data Use Agreement is dated,, and is between the ( Recipient ) and University of Miami, ( Covered Entity ). This Data Use Agreement is made in accordance

More information

COMMONWEALTH OF PENNSYLVANIA BUSINESS ASSOCIATE ADDENDUM

COMMONWEALTH OF PENNSYLVANIA BUSINESS ASSOCIATE ADDENDUM APPENDIX J Rev dated 11/24/2014 COMMONWEALTH OF PENNSYLVANIA BUSINESS ASSOCIATE ADDENDUM WHEREAS, the Pennsylvania Department of Human Services (Covered Entity) and Contractor (Business Associate) intend

More information

REGISTRY PARTICIPATION AGREEMENT

REGISTRY PARTICIPATION AGREEMENT REGISTRY PARTICIPATION AGREEMENT This Registry Participation Agreement ( Participation Agreement ) is made this day of, 20 ( Effective Date ), between the American Academy of Neurology Institute, a 501c3,

More information

Health Insurance Portability and Accountability Act (HIPAA) Terms and Conditions For Business Associates

Health Insurance Portability and Accountability Act (HIPAA) Terms and Conditions For Business Associates Health Insurance Portability and Accountability Act (HIPAA) Terms and Conditions For Business Associates I. OVERVIEW/DEFINITIONS The Health Insurance Portability and Accountability Act (HIPAA) is a federal

More information

HIPAA BUSINESS ASSOCIATE ADDENDUM

HIPAA BUSINESS ASSOCIATE ADDENDUM HIPAA BUSINESS ASSOCIATE ADDENDUM This Business Associate Addendum ( BAA ) is made between Cognito, LLC., a South Carolina corporation ( Cognito Forms ) and {OrganizationLegalName} ( Covered Entity or

More information

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT Attachment G HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT Health Insurance Portability and Accountability Act (HIPAA) Compliance This HIPAA Business Agreement

More information

Microsoft Online Subscription Agreement/Open Program License Agreement Amendment for HIPAA and HITECH Act Amendment ID MOS13

Microsoft Online Subscription Agreement/Open Program License Agreement Amendment for HIPAA and HITECH Act Amendment ID MOS13 Microsoft Online Subscription Agreement/Open Program License Agreement Amendment for HIPAA and HITECH Act Amendment ID To be valid, Customer must have accepted this Amendment as set forth in the Microsoft

More information

SCHEDULE D HIPPA BUSINESS PARTNER AGREEMENT

SCHEDULE D HIPPA BUSINESS PARTNER AGREEMENT SCHEDULE D HIPPA BUSINESS PARTNER AGREEMENT Whereas, the DPB, hereinafter the Covered Entity, as that term is defined by the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C.A. 1301

More information

AIUM Ultrasound Practice Accreditation Master Services Agreement & Business Associate Agreement (MSA/BAA)

AIUM Ultrasound Practice Accreditation Master Services Agreement & Business Associate Agreement (MSA/BAA) AIUM Ultrasound Practice Accreditation Master Services Agreement & Business Associate Agreement (MSA/BAA) Proposed amendments to this MSA/BAA may be submitted for consideration by paying a non-refundable

More information

Washington Producer Application

Washington Producer Application Washington Producer Application Please complete the application and the attached W-9 form and return with a copy of your Washington State Producer s license to Dental Health Services. Producer Name: Mailing

More information

AGREEMENT PURSUANT TO THE TERMS OF HIPAA ; HITECH ; and FIPA (Business Associate Agreement) (Revised August 2015)

AGREEMENT PURSUANT TO THE TERMS OF HIPAA ; HITECH ; and FIPA (Business Associate Agreement) (Revised August 2015) AGREEMENT PURSUANT TO THE TERMS OF HIPAA ; HITECH ; and FIPA (Business Associate Agreement) (Revised August 2015) THIS AGREEMENT made the day of, 20, by and between HOSPICE OF MARION COUNTY, INC., a Florida

More information

HIPAA STUDENT ASSOCIATE AGREEMENT

HIPAA STUDENT ASSOCIATE AGREEMENT HIPAA STUDENT ASSOCIATE AGREEMENT This Agreement dated as of, 20 is made by and between Petaluma Health Center (Hereinafter Covered Entity ) and (Hereinafter Student ). INTRODUCTION This Agreement governs

More information

AMWELL GROUP PRACTICE AGREEMENT

AMWELL GROUP PRACTICE AGREEMENT AMWELL GROUP PRACTICE AGREEMENT This Amwell Group Practice Agreement ( Agreement ) is a binding document between you (meaning the individual person or the entity that the individual represents that has

More information

Care Partners: Bridging Families, Clinics, and Communities to Advance Late-Life Depression Care Project, Phase 2

Care Partners: Bridging Families, Clinics, and Communities to Advance Late-Life Depression Care Project, Phase 2 Express License Instructions Care Partners: Bridging Families, Clinics, and Communities to Advance Late- Life Depression Care Project, Phase 2 Care Management Tracking Software and Data Storage Agreement

More information

Participation and HIPAA Compliance in the ACR National Radiology Data Registry

Participation and HIPAA Compliance in the ACR National Radiology Data Registry Participation and HIPAA Compliance in the ACR National Radiology Data Registry Your facility has indicated its willingness to participate in the American College of Radiology s National Radiology Data

More information

Section 125 Flexible Spending Account Plan Client Setup & Document Checklist

Section 125 Flexible Spending Account Plan Client Setup & Document Checklist Section 125 Flexible Spending Account Plan Client Setup & Document Checklist BASIC NEO 525 N. Cleveland-Massillon Rd. Suite 204 Akron, Ohio 44333 p: 1.800.775 (FLEX) 3539 f: (330) 572-8125 e: admin@flexneo.com

More information

HRA Administration - SummaCare Plan Getting Started Checklist

HRA Administration - SummaCare Plan Getting Started Checklist HRA Administration - SummaCare Plan Getting Started Checklist INITIAL SETUP 1. Setup paperwork submit executed forms to SummaCare to initiate services. a) Employer Plan Setup & Document Checklist b) Services

More information

MEDICARE NEXT GENERATION ACO PREFERRED PROVIDER AGREEMENT

MEDICARE NEXT GENERATION ACO PREFERRED PROVIDER AGREEMENT MEDICARE NEXT GENERATION ACO PREFERRED PROVIDER AGREEMENT THIS AGREEMENT ( Agreement ) is entered into as of the day of, 2016 (the Effective Date ) by and between Trinity Health ACO, Inc., a Delaware nonprofit

More information

Terms used, but not otherwise defined, in this Addendum shall have the same meaning as those terms in 45 CFR and

Terms used, but not otherwise defined, in this Addendum shall have the same meaning as those terms in 45 CFR and This Business Associate Addendum, effective April 1, 2003, is entered into by and between Guilford County and/or Guilford County Department of Social Services and/or Guilford County Department of Public

More information

UCLA Health System Data Use Agreement

UCLA Health System Data Use Agreement UCLA Health System Data Use Agreement The federal Health Insurance Portability and Accountability Act and the regulations promulgated thereunder (collectively referred to as the Privacy Rule ) permit the

More information

DEPARTMENT OF VERMONT HEALTH ACCESS GENERAL PROVIDER AGREEMENT

DEPARTMENT OF VERMONT HEALTH ACCESS GENERAL PROVIDER AGREEMENT DEPARTMENT OF VERMONT HEALTH ACCESS GENERAL PROVIDER AGREEMENT ARTICLE I. PURPOSE The purpose of this Agreement is for Department of Vermont Health Access (DVHA) and the undersigned Provider to contract

More information

RECIPROCAL BUSINESS ASSOCIATE AND DATA USE AGREEMENT BETWEEN THE PARTICIPATING PHYSICIAN ORGANIZATION AND MILLIMAN, INC.

RECIPROCAL BUSINESS ASSOCIATE AND DATA USE AGREEMENT BETWEEN THE PARTICIPATING PHYSICIAN ORGANIZATION AND MILLIMAN, INC. RECIPROCAL BUSINESS ASSOCIATE AND DATA USE AGREEMENT BETWEEN THE PARTICIPATING PHYSICIAN ORGANIZATION AND MILLIMAN, INC. THIS RECIPROCAL BUSINESS ASSOCIATE AND DATA USE AGREEMENT (this Agreement ) is by

More information

PURCHASE ORDER TERMS AND CONDITIONS

PURCHASE ORDER TERMS AND CONDITIONS PURCHASE ORDER TERMS AND CONDITIONS 1. Entire Agreement: (a) This Purchase Order including any addenda, sets forth the entire agreement relating to the purchased products or services and merges all prior

More information

Central Florida Regional Transportation Authority Table of Contents A. Introduction...1 B. Plan s General Policies...4

Central Florida Regional Transportation Authority Table of Contents A. Introduction...1 B. Plan s General Policies...4 Table of Contents A. Introduction...1 1. Purpose...1 2. No Third Party Rights...1 3. Right to Amend without Notice...1 4. Definitions...1 B. Plan s General Policies...4 1. Plan s General Responsibilities...4

More information

Partnership & Corporation Professional Liability Application

Partnership & Corporation Professional Liability Application Partnership & Corporation Professional Liability Application Producer Name Address Telephone Medical Professional Mutual Insurance Company ProSelect Insurance Company ProSelect National Insurance Company

More information

SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE

SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: USE OF LIMITED DATA SETS Page 1 of 3 No. HIPAA-27 Original Issue Date: 12/2003 Prepared by: Shoshana Milstein

More information

BROKER AGREEMENT. Wherein it is mutually agreed as follows:

BROKER AGREEMENT. Wherein it is mutually agreed as follows: This Broker Agreement (the Agreement ) made effective (the Effective Date ) between with an address of (hereinafter referred to as We, Our, Us or MGA ), Trustmark Life Insurance Company with an address

More information

GROUP HEALTH INCORPORATED SELLING AGENT AGREEMENT

GROUP HEALTH INCORPORATED SELLING AGENT AGREEMENT GROUP HEALTH INCORPORATED SELLING AGENT AGREEMENT This Agreement, made between Group Health Inc., having its principal office at 55 Water Street, New York, NY 10041 ("GHI"), and, having its principal office

More information

MNsure Certified Application Counselor Services Agreement with Tribal Nation Attachment A State of Minnesota

MNsure Certified Application Counselor Services Agreement with Tribal Nation Attachment A State of Minnesota MNsure Certified Application Counselor Services Agreement with Tribal Nation Attachment A State of Minnesota 1. MNsure Duties A. Application Counselor Duties (a) (b) (c) (d) (e) (f) Develop and administer

More information

HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE

HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE Refers to the Implementation Guides Based on X12 version 004010 A1 and version 005010 Companion Guide Version Number: 1.2 October 2, 2010 TABLE

More information

PsyBar, LLC 6600 France Avenue South, Suite 640 Edina, MN Telephone: (952) Facsimile: (952)

PsyBar, LLC 6600 France Avenue South, Suite 640 Edina, MN Telephone: (952) Facsimile: (952) PsyBar, LLC 6600 France Avenue South, Suite 640 Edina, MN 55435 Telephone: (952) 285-9000 Facsimile: (952) 848-1798 Updated 1/28/2016 PSYBAR, L. L. C. INDEPENDENT CONTRACTOR AGREEMENT PsyBar attempts to

More information

Texas Tech University Health Sciences Center HIPAA Privacy Policies

Texas Tech University Health Sciences Center HIPAA Privacy Policies Administration Policy 1.1 Glossary of Terms - HIPAA Effective Date: January 15, 2015 Reviewed Date: August 7, 2017 References: http://www.hhs.gov/ocr/hippa HSC HIPAA website http://www.ttuhsc.edu/hipaa/policies_procedures.aspx

More information

S T A N D A R D C H I R O P R A C T O R A G R E E M E N T & S I G N A T U R E P A G E

S T A N D A R D C H I R O P R A C T O R A G R E E M E N T & S I G N A T U R E P A G E S T A N D A R D C H I R O P R A C T O R A G R E E M E N T & S I G N A T U R E P A G E This Agreement is made by and between Soteria Healthcare Network, Inc., (herein Soteria ), a Georgia for-profit corporation

More information

Benefits Consultant' s Agreement

Benefits Consultant' s Agreement Benefits Consultant' s Agreement This "Agreement," is between Nassau County Board of County Commissioners, hereinafter referred to as "Client" and (MFB Financial TPA, Inc.) herein after referred to as

More information

B. Termination of Agreement. The Agreement may be terminated under any of the following circumstances:

B. Termination of Agreement. The Agreement may be terminated under any of the following circumstances: Data Sharing Agreement Agreement to Provide Administrative Services for Participating in the Early Retiree Reinsurance Program for Providence Health Plan Fully Insured and Self funded Groups 1. Purpose

More information

RECITALS. NOW THEREFORE, in consideration of the terms, covenants and agreements set forth in this Agreement, the Parties agree as follows:

RECITALS. NOW THEREFORE, in consideration of the terms, covenants and agreements set forth in this Agreement, the Parties agree as follows: MEMORANDUM OF AGREEMENT BETWEEN MUNICIPALITY AND COOK COUNTY DEPARTMENT OF PUBLIC HEALTH FOR PARTICIPATION IN THE 2009 CCDPH INFLUENZA A (H1N1) VACCINATION PROGRAM This MEMORANDUM OF AGREEMENT ( MOA )

More information

PLAN SPONSOR CERTIFICATION TO THE GROUP HEALTH PLAN

PLAN SPONSOR CERTIFICATION TO THE GROUP HEALTH PLAN PLAN SPONSOR CERTIFICATION TO THE GROUP HEALTH PLAN The self-funded group health plan (the Plan ) that you, as an employer, sponsor is a Covered Entity as defined by the Health Insurance Portability and

More information

BREACH NOTIFICATION POLICY

BREACH NOTIFICATION POLICY PRIVACY 2.0 BREACH NOTIFICATION POLICY Scope: All subsidiaries of Universal Health Services, Inc., including facilities and UHS of Delaware Inc. (collectively, UHS ), including UHS covered entities ( Facilities

More information

POLESTAR BENEFITS, INC. ADMINISTRATION AGREEMENT

POLESTAR BENEFITS, INC. ADMINISTRATION AGREEMENT POLESTAR BENEFITS, INC. ADMINISTRATION AGREEMENT THIS AGREEMENT (this Agreement ) is entered into by and between Polestar Benefits, Inc., ( Administrator ) and ( Employer ), effective BACKGROUND Employer

More information

Producer Agreement DDWA Product means an Individual or Group dental benefits product offered by Delta Dental of Washington.

Producer Agreement DDWA Product means an Individual or Group dental benefits product offered by Delta Dental of Washington. Producer Agreement This agreement, effective the day of is between DELTA DENTAL OF WASHINGTON, referred to as DDWA in this agreement, and, referred to as Producer in this agreement. In consideration of

More information

ENSPIRE QUALITY PARTNERS AGREEMENT FOR PARTICIPATION IN CLINICAL INTEGRATION PROGRAM

ENSPIRE QUALITY PARTNERS AGREEMENT FOR PARTICIPATION IN CLINICAL INTEGRATION PROGRAM ENSPIRE QUALITY PARTNERS AGREEMENT FOR PARTICIPATION IN CLINICAL INTEGRATION PROGRAM This Network Participation Agreement is by and between Enspire Quality Partners, LLC ( CI Organization ) and TIN: Name:

More information

Texas Tech University Health Sciences Center El Paso HIPAA Privacy Policies

Texas Tech University Health Sciences Center El Paso HIPAA Privacy Policies Administration Policy 1.1 Glossary of Terms - HIPAA Effective Date: January 15, 2015 References: http://www.hhs.gov/ocr/hipaa TTUHSC El Paso HIPAA website: http://elpaso.ttuhsc.edu/hipaa/ Policy Statement

More information

VACCINATION SERVICES OF AMERICA, INC. D/B/A TOTALWELLNESS INDEPENDENT CONTRACTOR AND BUSINESS ASSOCIATE AGREEMENT

VACCINATION SERVICES OF AMERICA, INC. D/B/A TOTALWELLNESS INDEPENDENT CONTRACTOR AND BUSINESS ASSOCIATE AGREEMENT VACCINATION SERVICES OF AMERICA, INC. D/B/A TOTALWELLNESS INDEPENDENT CONTRACTOR AND BUSINESS ASSOCIATE AGREEMENT By signing below, you are entering into an Independent Contractor Agreement (the Independent

More information

COLLECTION SERVICES AND BUSINESS ASSOCIATE AGREEMENT

COLLECTION SERVICES AND BUSINESS ASSOCIATE AGREEMENT COLLECTION SERVICES AND BUSINESS ASSOCIATE AGREEMENT THIS COLLECTION SERVICES AND BUSINESS ASSOCIATE AGREEMENT ("Agreement") made and entered into this day of, 20 by and between [COVERED ENTITY/HEALTHCARE

More information

Vendor seeks to deliver Medication Therapy Management Services to Members of Clients pursuant to one or more Client Agreements.

Vendor seeks to deliver Medication Therapy Management Services to Members of Clients pursuant to one or more Client Agreements. MTM NETWORK PARTICIPATION AGREEMENT This MTM Network Participation Agreement (the Agreement ) by and between OUTCOMES INCORPORATED, an IOWA CORPORATION ( Outcomes ) and the accepting party ("Vendor") is

More information

CLIENT UPDATE. HIPAA s Final Rule: The Impact on Covered Entities, Business Associates and Subcontractors

CLIENT UPDATE. HIPAA s Final Rule: The Impact on Covered Entities, Business Associates and Subcontractors CLIENT UPDATE February 20, 2013 HIPAA s Final Rule: The Impact on Covered Entities, Business Associates and Subcontractors On January 25, 2013, the U.S. Department of Health and Human Services ( DHHS )

More information

BASIC COBRA. Thank you for choosing BASIC for your COBRA Administration! Please read the information below before you proceed with implementation.

BASIC COBRA. Thank you for choosing BASIC for your COBRA Administration! Please read the information below before you proceed with implementation. BASIC COBRA Thank you for choosing BASIC for your COBRA Administration! Please read the information below before you proceed with implementation. To provide you with the highest quality service, all information

More information

Oregon Health & Science University STANDARD CONTRACT PROVISIONS PROFESSIONAL SERVICES CONTRACT

Oregon Health & Science University STANDARD CONTRACT PROVISIONS PROFESSIONAL SERVICES CONTRACT Oregon Health & Science University STANDARD CONTRACT PROVISIONS PROFESSIONAL SERVICES CONTRACT 1. Independent Contractor Status. OHSU and the Contractor intend that the Contractor s relationship to OHSU

More information

St. Jude Children's Research Hospital Terms and Conditions for Goods Purchased

St. Jude Children's Research Hospital Terms and Conditions for Goods Purchased St. Jude Children's Research Hospital Terms and Conditions for Goods Purchased These Terms and Conditions are incorporated into the St. Jude Children s Research Hospital, Inc. (SJCRH) Purchase Order and

More information

WARRANT AGREEMENT. Issue Date: April [ ], 2015 (the Effective Date )

WARRANT AGREEMENT. Issue Date: April [ ], 2015 (the Effective Date ) THIS WARRANT AGREEMENT AND THE SECURITIES ISSUABLE UPON THE EXERCISE HEREOF HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, OR ANY STATE SECURITIES LAWS. THEY MAY NOT BE SOLD, OFFERED

More information

HIPAA PRIVACY POLICY AND PROCEDURES FOR PROTECTED HEALTH INFORMATION THE APPLICABLE WELFARE BENEFITS PLANS OF MICHIGAN CATHOLIC CONFERENCE

HIPAA PRIVACY POLICY AND PROCEDURES FOR PROTECTED HEALTH INFORMATION THE APPLICABLE WELFARE BENEFITS PLANS OF MICHIGAN CATHOLIC CONFERENCE HIPAA PRIVACY POLICY AND PROCEDURES FOR PROTECTED HEALTH INFORMATION THE APPLICABLE WELFARE BENEFITS PLANS OF MICHIGAN CATHOLIC CONFERENCE Policy Preamble This privacy policy ( Policy ) is designed to

More information

Issuer Appointment of an Investment Bank Designated Advisor for Disclosure

Issuer Appointment of an Investment Bank Designated Advisor for Disclosure Issuer Appointment of an Investment Bank Designated Advisor for Disclosure Full Name and Address of the Issuer: (the Issuer ) Address: Full Name and Address of the Investment Bank Designated Advisor for

More information

Producer Agreement. Submission Checklist. Please return the required documentation to: Or mail to:

Producer Agreement. Submission Checklist. Please return the required documentation to: Or mail to: Submission Checklist Please submit the following documentation with this signed Producer Agreement for complete processing of your appointment with CoPower and payment of commissions: CoPower Producer

More information

DATA TRANSMISSION SERVICES AGREEMENT

DATA TRANSMISSION SERVICES AGREEMENT DATA TRANSMISSION SERVICES AGREEMENT This Data Transmission Services Agreement (the "Agreement") is effective on, (the Effective Date ) and governs the Data Transmission Services to be provided by GREAT

More information