You can open the Business Associate Agreement Template in multiple formats, including PDF, Word, and Google Docs.
Business Associate Agreement Template Printable | Editable FormSample
[Name of the Business Associate]
[Business Associate’s ID]
[Business Associate’s Address]
[Business Associate’s Phone]
[Business Associate’s Email]
[Name of the Covered Entity]
[Covered Entity’s ID]
[Covered Entity’s Address]
This Agreement is entered into as of [Effective Date], to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable legal requirements regarding the handling of protected health information (PHI).
For the purpose of this Agreement, terms such as “Protected Health Information,” “Business Associate,” and “Covered Entity” shall have the meanings assigned to them under HIPAA.
The Business Associate agrees to:
The Business Associate may use or disclose PHI only to perform its obligations under this Agreement and as permitted by HIPAA regulations.
Either party may terminate this Agreement if the other party fails to comply with its terms. Additionally, upon termination, the Business Associate will return or destroy all PHI.
The Business Associate agrees to indemnify and hold harmless the Covered Entity from any claims arising from the Business Associate’s breach of this Agreement or HIPAA.
This Agreement may be amended only by written agreement signed by both parties. Any amendments shall comply with applicable laws and regulations.
[Signature of the Business Associate]
[Name of the Business Associate]
[Signature of the Covered Entity]
[Name of the Covered Entity]
[Name of the Business Associate]
[Business Associate’s ID]
[Business Associate’s Address]
[Business Associate’s Phone]
[Business Associate’s Email]
[Name of the Covered Entity]
[Covered Entity’s ID]
[Covered Entity’s Address]
This Business Associate Agreement (“Agreement”) is made effective as of [Effective Date] for the purpose of ensuring that the handling of Protected Health Information (PHI) complies with applicable federal and state laws.
Both parties agree to comply with all federal and state regulations regarding PHI, including but not limited to HIPAA and HITECH.
The Business Associate agrees to implement administrative, physical, and technical safeguards to protect PHI and prevent unauthorized access.
The Business Associate is permitted to use PHI only for the following purposes: [List allowed uses], and must not engage in any sales or marketing activities using PHI.
The Covered Entity shall have the right to conduct periodic audits of the Business Associate to ensure compliance with this Agreement.
This Agreement shall be effective for a term of [Specify Term], at which point it may be renewed or terminated by either party with [Notice Period] notice.
This Agreement will be governed by the laws of [Jurisdiction].
[Signature of the Business Associate]
[Name of the Business Associate]
[Signature of the Covered Entity]
[Name of the Covered Entity]
Form
Please complete the form below to create the Business Associate Agreement Template. All fields must be filled out to ensure compliance with HIPAA regulations and to clarify the responsibilities between the parties. We provide examples to guide you through each step. Business Associate Agreement Template 1. Business Associate Information 2. Covered Entity Information 3. Purpose of the Agreement 4. Definition of Protected Health Information (PHI) 5. Responsibilities of the Business Associate 6. Safeguards and Security 7. Reporting of Breaches 8. Termination of Agreement 9. Confidentiality Obligations 10. Signatures and Acknowledgment 11. Declaration and Signatures
PDF
WORD
Business Associate Agreement Template Printable | Editable FormPrintable
