You can open the Business Associate Agreement HIPAA Template in multiple formats, including PDF, Word, and Google Docs.
Business Associate Agreement HIPAA Template Printable | Editable FormSample
[Name of the Covered Entity]
[Covered Entity’s ID]
[Covered Entity’s Address]
[Covered Entity’s Phone]
[Covered Entity’s Email]
[Name of the Business Associate]
[Business Associate’s ID]
[Business Associate’s Address]
This Business Associate Agreement (the “Agreement”) is made as of [Effective Date] to establish the terms and conditions under which [Business Associate’s Name] will handle Protected Health Information (PHI) in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
For purposes of this Agreement, “Protected Health Information (PHI)” shall have the same meaning as defined in HIPAA.
The Business Associate agrees to:
1. Implement appropriate safeguards to prevent unauthorized use or disclosure of PHI.
2. Report any use or disclosure of PHI not provided for by this Agreement.
3. Ensure that any subcontractors comply with the same restrictions and conditions.
The Business Associate may use or disclose PHI only as permitted or required by this Agreement and HIPAA.
This Agreement shall commence on [Effective Date] and shall remain in effect until terminated by either party. Either party may terminate this Agreement if the other party fails to comply with a material obligation.
This Agreement may not be amended except in writing and signed by both parties. The Agreement shall be governed by the laws of [State].
[Signature of the Covered Entity’s Authorized Representative]
[Name of the Covered Entity’s Authorized Representative]
[Signature of the Business Associate’s Authorized Representative]
[Name of the Business Associate’s Authorized Representative]
[Name of the Covered Entity]
[Covered Entity’s ID]
[Covered Entity’s Address]
[Covered Entity’s Phone]
[Covered Entity’s Email]
[Name of the Business Associate]
[Business Associate’s ID]
[Business Associate’s Address]
This Agreement establishes the responsibilities of the Business Associate with respect to PHI and outlines the obligations that both parties employ to comply with HIPAA regulations.
The purpose of this Agreement is to ensure compliance with HIPAA to safeguard PHI during the exchange of information between the parties.
The Business Associate will utilize physical, administrative, and technical safeguards to protect the confidentiality, integrity, and availability of PHI.
In the event of a breach of unsecured PHI, the Business Associate must notify the Covered Entity without unreasonable delay and within [Number] days.
Upon termination of this Agreement, the Business Associate will return or destroy all PHI received from the Covered Entity, retaining no copies.
Both parties agree to indemnify and hold harmless each other from any claims arising from breaches of the terms of this Agreement.
[Signature of the Covered Entity’s Authorized Representative]
[Name of the Covered Entity’s Authorized Representative]
[Signature of the Business Associate’s Authorized Representative]
[Name of the Business Associate’s Authorized Representative]
Form
Please complete the form below to create the Business Associate Agreement (HIPAA) Template. All fields must be filled out to ensure compliance with HIPAA regulations and a clear understanding between the parties involved. We provide examples to guide you through each step. Business Associate Agreement (HIPAA) Template 1. Business Associate Information 2. Covered Entity Information 3. Agreement Purpose 4. Definition of Protected Health Information 5. Permitted Uses and Disclosures of PHI 6. Safeguards 7. Reporting Security Incidents 8. Responsibilities Upon Termination 9. Indemnification 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
Business Associate Agreement HIPAA Template Printable | Editable FormPrintable
