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\\\DC - 67908/0004 - 1678033 v1
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 1The 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
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