HIPAA Business Associate Agreement - Third Parties
Please note that the attached Business Associate Agreement has been updated as of August 12, 2013 to reflect the new requirements set forth in the Health Information Technology for Economic & Clinical Health Act ("HITECH"), Subtitle D-Privacy (§§13400-13424), as part of the American Recovery and Reinvestment Act of 2009, and as amended
It is recommended that all entities having a business relationship with MedPro Group Inc., or any subsidiary of, or entity controlled by, MedPro Group Inc., that uses, transmits, or discloses information which constitutes Protected Health Information ("MedPro Group"), complete this updated version and retain a copy for their records.
Instructions for Completing the HIPAA Business Associate Agreement
- In the first box, enter your initials indicating you understand you are entering into a legally binding electronic transaction.
- Enter your first and last name as a representation of your signature. By signing this agreement, you represent that you are authorized to sign on behalf of the individual, partnership, professional corporation, or other entity on whose behalf this agreement is made.
- Validate your electronic signature by entering the requested contact information.
- After clicking "I Accept," please print out a copy of the fully completed agreement.
- You Are Finished - It's That Simple!
Please save or print this form as confirmation that you entered into this agreement with MedPro Group.
Please note: Due to the large number of requests, this electronic format is the exclusive method to enter into a Business Associate Agreement with MedPro Group. Paper submissions of this form or alternative forms will be returned.
Thank You For Using MedPro Group's Electronic HIPAA Business Associate Agreement!
BUSINESS ASSOCIATE AGREEMENT
This agreement ("Agreement") is effective upon its execution and delivery to MedPro Group Inc., or any subsidiary of, or entity controlled by, MedPro Group Inc., that uses, transmits, or discloses information which constitutes Protected Health Information ("PHI"), as defined herein, (hereafter referred to as "MedPro Group"), as further indicated below, by and between the undersigned services provider (hereafter referred to as "Business Associate") and MedPro Group.
MedPro Group and Business Associate mutually agree to the terms of this Agreement to comply with the requirements of the Standards for Security and Privacy of Individually Identifiable Information (the "Security and Privacy Regulations"), as applicable, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as amended, as well as with the Health Information Technology for Economic & Clinical Health Act ("HITECH"), Subtitle D-Privacy (§§13400-13424), as part of the American Recovery and Reinvestment Act of 2009, as amended.
MedPro Group and Business Associate have a business relationship such that Business Associate may be deemed a business associate of MedPro Group.
MedPro Group may disclose certain information to Business Associate pursuant to the terms of this Agreement, some of which may constitute PHI.
MedPro Group and Business Associate intend to protect the privacy and provide for the security of PHI disclosed to Business Associate pursuant to this Agreement in compliance with the HIPAA Security and Privacy Regulations and HITECH.
HIPAA Security and Privacy Regulations and HITECH require MedPro Group to enter into a contract containing specific requirements with Business Associate prior to the disclosure of PHI, as set forth in this Agreement.
- The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.
- Business Associate. "Business Associate" shall generally have the same meaning as the term "business associate" at 45 CFR 160.103, and in reference to the party to this agreement.
- Covered Entity. "Covered Entity" shall generally have the same meaning as the term "covered entity" at 45 CFR 160.103.
- HIPAA Rules. "HIPAA Rules" shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164.
B. Obligations and Activities of Business Associate
Business Associate agrees to:
- Not use or disclose protected health information other than as permitted or required by the Agreement or as required by law;
- Use appropriate safeguards, and comply with 45 CFR Part 164 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the Agreement;
- Report to MedPro Group any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware within 60 days after the use or disclosure, including the number of individuals impacted, type of information involved in the breach, the date of breach, and the circumstances of the breach.
- In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of Business Associate agree to the same restrictions, conditions, and requirements that apply to Business Associate with respect to such information;
- Make available protected health information in a designated record set to MedPro Group as necessary to satisfy MedPro Group's obligations, if any, under 45 CFR 164.524;
- Make any amendment(s) to protected health information in a designated record set as directed or agreed to by MedPro Group pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy MedPro Group's obligations, if any, under 45 CFR 164.526;
- Maintain and make available the information required to provide an accounting of disclosures to MedPro Group as necessary to satisfy MedPro Group's obligations, if any, under 45 CFR 164.528;
- To the extent Business Associate is to carry out one or more of MedPro Group's obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to MedPro Group in the performance of such obligation(s); and
- Make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules
C. Permitted Uses and Disclosures by Business Associate
- Business Associate may only use or disclose protected health information as necessary to perform any services necessary or required as a service provider to MedPro Group.
- Business Associate may use or disclose protected health information as required by law.
- Business Associate agrees to make uses and disclosures and requests for protected health information subject to the following minimum necessary requirements: as necessary or required in order to provide services to MedPro Group.
- Business Associate may not use or disclose protected health information in a manner that would violate Subpart E of 45 CFR Part 164 if done by MedPro Group, except with regards to the data aggregation, management, administration and legal responsibilities of the Business Associate.
- Business Associate may use protected health information for the Business Associate's proper management and administration or to carry out the legal responsibilities of the Business Associate.
- Business Associate may disclose protected health information for the proper management and administration of Business Associate or to carry out the legal responsibilities of the Business Associate, provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.
- Business Associate may provide data aggregation services relating to the health care operations of MedPro Group.
D. Term and Termination
- Term. This Agreement shall continue in force so long as any underlying contract between MedPro Group and Business Associate remains in force.
- Termination for Cause. MedPro Group shall provide written notice if it determines that Business Associate has breached any material provision of this Agreement. Regardless of whether Business Associate cures the breach, MedPro Group may, at its sole discretion, terminate this Agreement.
- Obligations of Business Associate Upon Termination. Upon termination of this Agreement for any
reason, Business Associate, with respect to protected health information received from MedPro Group, or
created, maintained, or received by Business Associate on behalf of MedPro Group, shall:
- Retain only that protected health information which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;
- Destroy the remaining protected health information that Business Associate still maintains in any form and provide certification of destruction to MedPro Group within 30 days after the termination;
- Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information to prevent use or disclosure of the protected health information, other than as provided for in this Section, for as long as Business Associate retains the protected health information;
- Not use or disclose the protected health information retained by Business Associate other than for the purposes for which such protected health information was retained and subject to the same conditions set out at above which applied prior to termination; and
- Destroy the protected health information 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.
- Survival. The obligations of Business Associate under this Section shall survive the termination of this Agreement.
- Regulatory References. A reference in this Agreement to a section in the HIPAA Rules means the section as in effect or as amended.
- Amendment. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the requirements of the HIPAA Rules and any other applicable law.
- Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance with the HIPAA Rules.
IN WITNESS WHEREOF, MedPro Group and the Business Associate execute this Business Associate Agreement to be effective as of the date signed and submitted by the Business Associate as indicated below:
MEDPRO GROUP INC.
Trent C. Heinemeyer, Secretary
5814 Reed Road
Fort Wayne, Indiana 46835
BY TYPING YOUR INITIALS IN THE BOX AT THE END OF THIS SENTENCE, YOU ACKNOWLEDGE THAT IT IS YOUR INTENT THAT YOUR FIRST AND LAST NAME, AS TYPED IN THE SIGNATURE BOX BELOW, WILL SERVE AS YOUR SIGNATURE FOR THE PURPOSE OF THIS BUSINESS ASSOCIATE AGREEMENT AND THAT YOU AGREE TO CONDUCT THIS TRANSACTION ELECTRONICALLY.