You can open the HIPAA Business Associate Agreement Template in multiple formats, including PDF, Word, and Google Docs.
HIPAA Business Associate Agreement 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 agreement is made to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) regarding the protection of patient information.
The purpose of this Agreement is to safeguard the confidentiality of Protected Health Information (PHI) disclosed between the parties for health care operations, payment, and other associated activities.
“Protected Health Information” shall mean any information that is subject to protection under HIPAA regulations that is created, received, maintained, or transmitted by either party.
The Business Associate agrees to: (a) use and disclose PHI only as permitted or required by this Agreement or as required by law; (b) implement appropriate safeguards to prevent unauthorized use or disclosure of PHI; (c) report any unauthorized use or disclosure of PHI to the Covered Entity.
This Agreement shall commence on [Effective Date] and continue until terminated by either party. Upon termination, the Business Associate must return or destroy all PHI received from the Covered Entity.
The Business Associate agrees to indemnify and hold harmless the Covered Entity from any claims, damages, liabilities, costs, or expenses arising from a breach of this Agreement.
This Agreement shall be governed by and construed in accordance with the laws of [Jurisdiction].
[Signature of the Covered Entity]
[Name of the Covered Entity]
[Signature of the Business Associate]
[Name of the Business Associate]
[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 is intended to comply with HIPAA regulations by outlining the responsibilities regarding the handling of PHI.
The Business Associate agrees to use PHI only for the purposes specified in this Agreement and in accordance with HIPAA requirements.
The Business Associate will implement 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 shall notify the Covered Entity without unreasonable delay and not later than 60 days after discovery.
The Business Associate shall ensure that any subcontractors that create, receive, maintain, or transmit PHI on its behalf agree to the same restrictions and conditions as outlined in this agreement.
The Covered Entity shall have the right to conduct audits of the Business Associate’s operations while this Agreement is in effect to ensure compliance.
Upon termination of this Agreement, the Business Associate shall return or destroy all PHI received from the Covered Entity, at the Covered Entity’s discretion.
[Signature of the Covered Entity]
[Name of the Covered Entity]
[Signature of the Business Associate]
[Name of the Business Associate]
Form
Please complete the form below to create the HIPAA Business Associate Agreement Template. All fields must be filled out to ensure compliance with regulations. We provide examples to guide you through each step. HIPAA Business Associate Agreement Template 1. Business Associate Information 2. Covered Entity Information 3. Purpose of Agreement 4. Definition of PHI 5. Permitted Uses and Disclosures 6. Safeguards and Security Measures 7. Reporting Breaches 8. Term and Termination 9. Return or Destruction of PHI 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
HIPAA Business Associate Agreement Template Printable | Editable FormPrintable