HIPAA
Business Associate Agreement (BAA)
With Security Rule & Omnibus Amendment
Section I. Definitions
- Agreement. “Agreement” shall mean the “HIPAA Business Associate Agreement with Security Rule and Omnibus Amendment.”
- Business Associate. “Business Associate” shall mean TherapyRising
- Covered Entity. “Covered Entity” shall mean You, our client
- Individual. “Individual” shall have the same meaning as the term “individual” in 45 CFR § 164.501 and shall include a person who qualifies as a personal representative in accordance with 45 CFR § 164.502(g).
- Privacy Rule. “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR Part 160 and Part 164, Subparts A and E.
- Security Rule. “Security Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR Part 164, Subpart C.
- HIPAA. “HIPAA” shall mean the Health Insurance Portability and Accountability Act of 1996.
- Protected Health Information. “Protected Health Information (PHI)” shall have the same meaning as the term “protected health information” in 45 CFR § 164.501 and 45 CFR § 160.103, limited to the information created, received, maintained or transmitted by Business Associate from or on behalf of Covered Entity.
- Electronic Protected Health Information (EPHI). “Electronic Protected Health Information (EPHI)” shall have the same meaning as the term “electronic protected health information” in 45 CFR § 160.103, limited to the information created, received, maintained or transmitted by Business Associate on behalf of Covered Entity.
- Required By Law. “Required By Law” shall have the same meaning as the term “required by law” in 45 CFR § 164.501.
- Secretary. “Secretary” shall mean the Secretary of the Department of Health and Human Services or his/her designee.
Section II. Obligations and Activities of Business Associate
- Business Associate agrees to not use or disclose PHI or EPHI other than as permitted or required by this Agreement or as required by law.
- Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the PHI and/or EPHI other than as provided for by this Agreement.
- Business Associate agrees to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of EPHI, as required by the HIPAA Security Rule (45 CFR § 164, Subpart C).
- Business Associate agrees to report to Covered Entity as soon as practicable any security incident of which Business Associate becomes aware. A security incident is an attempted or successful unauthorized access, use, disclosure, modification or destruction of PHI and/or EPHI, or an attempted or successful interference with an information system that stores or
- Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of PHI and/or EPHI by Business Associate in violation of the requirements of this Agreement.
- Business Associate is aware that he/she is directly liable for compliance with these requirements according to the Omnibus Rule.
- Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides PHI and/or EPHI received from, or created or received by Business Associate on behalf of Covered Entity agrees to the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such information.
- Business Associate agrees to provide access, at the request of Covered Entity, and in the time and manner to be set by Covered Entity, to PHI and/or EPHI in a Designated Record Set, to Covered Entity or, as directed by Covered Entity, to an Individual in order to meet the requirements under 45 CFR § 164.524 and 45 CFR § 160.103.
- Business Associate agrees to make any amendment(s) to PHI and/or EPHI in a Designated Record Set that the Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 and 45 CFR § 160.103 at the request of Covered Entity or an Individual, and in the time and manner to be set by the Covered Entity.
- Business Associate agrees to make available to the Covered Entity or to the Secretary of the U.S. Department of Health and Human Services (Secretary) Business Associate’s documents and data relating to safeguarding the security of EPHI, including but not limited to: internal practices, books and records, policies and procedures, and audit logs reflecting accessing of PHI and EPHI. Business Associate shall make such documents and data available in a time and manner requested by Covered Entity or designated by the Secretary, for purposes of: (i) the Secretary determining Covered Entity’s compliance with the HIPAA Privacy Rule and Security Rule; or (ii) Covered Entity determining Business Entity’s compliance with the HIPAA Privacy Rule and Security Rule.
- EPHI is to be transmitted between COVERED ENTITY and BUSINESS ASSOCIATE by password protected documents sent via email and/or encrypted software.
- Business Associate agrees to document such disclosures of PHI and/or EPHI and information related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI and/or EPHI in accordance with 45 CFR § 164.528 and 45 CFR § 160.103.
- Business Associate agrees to provide to Covered Entity or an Individual, in time and manner to be set by Covered Entity, information collected in accordance with Section II(i) of this Agreement, to permit Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI and/or EPHI in accordance with 45 CFR § 164.528 and 45 CFR § 160.103.
- Employees, Subcontractors, or any other persons or entities to whom Business Associate allows access to PHI and/or EPHI will only have access to PHI and/or EPHI as follows:
transmits EPHI.
Job Title/Position/Type of Contractor/or Office Associate | Type of PHI/EPHI to which this person has access | This person’s access to PHI/EPHI is limited to the following purposes (if applicable) |
1. Website Developer | Client email, phone number, date of birth, insurance information, and reason for therapy. | Transferring secure (HIPAA compatible) email from website by the client to the therapist. |
Section III. Permitted Uses and Disclosures by Business Associate
General Use and Disclosure Provisions
- Specify purposes:
Except as otherwise limited in this Agreement, Business Associate may use or disclose PHI and/or EPHI on behalf of, or to provide services to, Covered Entity for the following purposes, if such use or disclosure of PHI and/or EPHI would not violate the Privacy Rule and Security Rule if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity, which include use of PHI and/or EPHI for accounting, bookkeeping, filing, insurance reimbursement procedures, providing legal assistance, scheduling, and/or assisting Covered Entity or Covered Entity’s clients in any way related to business operations based on Business Associate’s professional area of expertise. - Refer to underlying services agreement:
Except as otherwise limited in this Agreement, Business Associate may use or disclose PHI and/or EPHI to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in this document, provided that such use or disclosure would not violate the Privacy Rule and Security Rule if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity.
Section IV. Obligations of Covered Entity
Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions
- Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy practices of Covered Entity in accordance with 45 CFR § 164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI and/or EPHI.
- Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose PHI and/or EPHI, to the extent that such changes may affect Business Associate’s use or disclosure of PHI and/or EPHI.
- Covered Entity shall notify Business Associate of any restriction to the use or disclosure of PHI and/or EPHI that Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI and/or EPHI.
Section V. Permissible Requests by Covered Entity
Covered Entity shall not request Business Associate to use or disclose PHI and/or EPHI in any manner that would not be permissible under the Privacy Rule and Security Rule if done by Covered Entity. An exception to this policy is if the Business Associate will use or disclose PHI and/or EPHI for, and the contract includes provisions for, data aggregation or management and administrative activities of Business Associate.
Section VI. Term and Termination
- Term. The Term of this Agreement shall be effective as of the date you sign up and create your account, and shall terminate when all of the PHI and/or EPHI provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy PHI and/or EPHI, protections are extended to such information, in accordance with the termination provisions in this Section.
- Termination for Cause. Upon Covered Entity’s knowledge of a material breach by Business Associate, Covered Entity shall either:
- Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreement if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity;
- Immediately terminate this Agreement if Business Associate has breached a material term of this Agreement and cure is not possible; or
- If neither termination nor cure are feasible, Covered Entity shall report the violation to the Secretary.
- Effect of Termination.
- Except as provided in paragraph (2) of this section, upon termination of this Agreement, for any reason, Business Associate shall return or destroy all PHI and/or EPHI received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to PHI and/or EPHI that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the PHI and/or EPHI.
- In the event that Business Associate determines that returning or destroying the PHI or EPHI is infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction infeasible in writing. Upon Covered Entity’s written acceptance that return or destruction of PHI and/or EPHI is infeasible, Business Associate shall extend the protections of this Agreement to such PHI and/or EPHI and limit further uses and disclosures of such PHI and/or EPHI to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such PHI and/or EPHI.
Business Associate’s signature below indicates that he/she has read this document thoroughly and agrees to abide by the terms and conditions stated:
BUSINESS ASSOCIATE:
Print Name: Qmars Imandel
Print Title: Owner
Signature:
Date: December 4, 2024