Business Associate Agreement

Required Optional Completed

Business Information

Business Associate Name

Contact Email

Contact Phone

HIPAA Security/Privacy Officer

Services you will provide

Do you currently have a BAA signed with the covered entity, West Orlando Internal Medicine?

Yes

Background

Has your company conducted HIPAA Training?

Yes

Date of your most recent HIPAA Training

Has your company undergone a Risk Assessment

Yes

Date of your most recent Risk Assessment

Do you have a set of polices and procedures?

Yes

Has the organization been investigated for a HIPAA violation?

Yes

Please explain

Subcontractors

Yes

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?

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

Your Name

Title

Signature

Congrats!

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

If you need to update your demographics informations; email, phone, address, etc.

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Do you need to book an appointment?

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Please tell us how we are doing!

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