Business Associate Agreement

Required Optional Completed
Business Information





Background



Subcontractors

Business Information

Business Associate Name
Phone Number
Email Address
HIPAA Security/Privacy Officer
Services you will provide
Do you currently have a BAA signed with the covered entity?

Background

Has your company conducted HIPAA Training?
Date of your most recent HIPAA Training
Has your company undergone a Risk Assessment
Date of your most recent Risk Assessment
Do you have a set of polices and procedures?
Has the organization been investigated for a HIPAA violation?
Explanation Reason for vialoation

Subcontractors

Business Associate Signature

Congrats!

You have successfully completed your business associate agreement paperwork!
You will be notified with a copy after it is countersigned.

Your number:

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