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Education Materials
Medical Privacy - National Standards to Protect
the Privacy of Personal Health Information
SAMPLE BUSINESS ASSOCIATE CONTRACT PROVISIONS
(Published in FR 67 No.157 pg.53182, 53264 (August 14, 2002))
Statement of Intent
The Department provides these sample business
associate contract provisions in response to numerous requests for
guidance. This is only sample language. These provisions are designed to
help covered entities more easily comply with the business associate
contract requirements of the Privacy Rule. However, use of these sample
provisions is not required for compliance with the Privacy Rule. The
language may be amended to more accurately reflect business arrangements
between the covered entity and the business associate.
These or similar provisions may be incorporated into
an agreement for the provision of services between the entities or they
may be incorporated into a separate business associate agreement. These
provisions only address concepts and requirements set forth in the
Privacy Rule and alone are not sufficient to result in a binding
contract under State law. They do not include many formalities and
substantive provisions that are required or typically included in a
valid contract. Reliance on this sample is not sufficient for compliance
with State law and does not replace consultation with a lawyer or
negotiations between the parties to the contract.
Furthermore, a covered entity may want to include
other provisions that are related to the Privacy Rule but that are not
required by the Privacy Rule. For example, a covered entity may want to
add provisions in a business associate contract in order for the covered
entity to be able to rely on the business associate to help the covered
entity meet its obligations under the Privacy Rule. In addition, there
may be permissible uses or disclosures by a business associate that are
not specifically addressed in these sample provisions, for example
having a business associate create a limited data set. These and other
types of issues will need to be worked out between the parties.
Sample Business Associate Contract Provisions
Definitions (alternative approaches)
Catch-all definition:
Terms used, but not otherwise defined, in this
Agreement shall have the same meaning as those terms in the Privacy
Rule.
Examples of specific definitions:
- Business Associate.
"Business Associate" shall mean [Insert Name of Business Associate].
- Covered Entity.
"Covered Entity" shall mean [Insert Name of Covered Entity].
- 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.
- Protected Health Information.
"Protected Health Information" shall have the same meaning as the
term "protected health information" in 45 CFR § 164.501, limited to
the information created or received by Business Associate from or 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 designee.
Obligations and Activities of Business Associate
- Business Associate agrees to not use or disclose
Protected Health Information other than as permitted or required by
the Agreement or as Required By Law.
- Business Associate agrees to use appropriate
safeguards to prevent use or disclosure of the Protected Health
Information other than as provided for by this Agreement.
- Business Associate agrees to mitigate, to the
extent practicable, any harmful effect that is known to Business
Associate of a use or disclosure of Protected Health Information by
Business Associate in violation of the requirements of this Agreement.
[This provision may be included if it is appropriate for the Covered
Entity to pass on its duty to mitigate damages to a Business
Associate.]
- Business Associate agrees to report to Covered
Entity any use or disclosure of the Protected Health Information not
provided for by this Agreement of which it becomes aware.
- Business Associate agrees to ensure that any agent,
including a subcontractor, to whom it provides Protected Health
Information 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 [Insert
negotiated terms], to Protected Health Information 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.
[Not necessary if business associate does not have protected health
information in a designated record set.]
- Business Associate agrees to make any amendment(s)
to Protected Health Information in a Designated Record Set that the
Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 at
the request of Covered Entity or an Individual, and in the time and
manner [Insert negotiated terms]. [Not necessary if business associate
does not have protected health information in a designated record
set.]
- Business Associate agrees to make internal
practices, books, and records, including policies and procedures and
Protected Health Information, relating to the use and disclosure of
Protected Health Information received from, or created or received by
Business Associate on behalf of, Covered Entity available [to the
Covered Entity, or] to the Secretary, in a time and manner [Insert
negotiated terms] or designated by the Secretary, for purposes of the
Secretary determining Covered Entity's compliance with the Privacy
Rule.
- Business Associate agrees to document such
disclosures of Protected Health Information 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
Protected Health Information in accordance with 45 CFR § 164.528.
- Business Associate agrees to provide to Covered
Entity or an Individual, in time and manner [Insert negotiated terms],
information collected in accordance with Section [Insert Section
Number in Contract Where Provision (i) Appears] of this Agreement, to
permit Covered Entity to respond to a request by an Individual for an
accounting of disclosures of Protected Health Information in
accordance with 45 CFR § 164.528.
Permitted Uses and Disclosures by Business
Associate
General Use and Disclosure Provisions [(a) and (b)
are alternative approaches]
- Specify purposes:
Except as otherwise limited in this Agreement,
Business Associate may use or disclose Protected Health Information on
behalf of, or to provide services to, Covered Entity for the following
purposes, if such use or disclosure of Protected Health Information
would not violate the Privacy Rule if done by Covered Entity or the
minimum necessary policies and procedures of the Covered Entity:
[List Purposes].
- Refer to underlying services agreement:
Except as otherwise limited in this Agreement,
Business Associate may use or disclose Protected Health Information to
perform functions, activities, or services for, or on behalf of,
Covered Entity as specified in [Insert Name of Services Agreement],
provided that such use or disclosure would not violate the Privacy
Rule if done by Covered Entity or the minimum necessary policies and
procedures of the Covered Entity.
Specific Use and Disclosure Provisions [only
necessary if parties wish to allow Business Associate to engage in such
activities]
- Except as otherwise limited in this Agreement,
Business Associate may use Protected Health Information for the proper
management and administration of the Business Associate or to carry
out the legal responsibilities of the Business Associate.
- Except as otherwise limited in this Agreement,
Business Associate may disclose Protected Health Information for the
proper management and administration of the Business Associate,
provided that disclosures are Required By Law, or Business Associate
obtains reasonable assurances from the person to whom the information
is disclosed that it will remain confidential and used or further
disclosed only as Required By Law or for the purpose for which it was
disclosed to the person, and the person notifies the Business
Associate of any instances of which it is aware in which the
confidentiality of the information has been breached.
- Except as otherwise limited in this Agreement,
Business Associate may use Protected Health Information to provide
Data Aggregation services to Covered Entity as permitted by 42 CFR §
164.504(e)(2)(i)(B).
- Business Associate may use Protected Health
Information to report violations of law to appropriate Federal and
State authorities, consistent with § 164.502(j)(1).
Obligations of Covered Entity
Provisions for Covered Entity to Inform Business
Associate of Privacy Practices and Restrictions [provisions dependent on
business arrangement]
- 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
Protected Health Information.
- Covered Entity shall notify Business Associate of
any changes in, or revocation of, permission by Individual to use or
disclose Protected Health Information, to the extent that such changes
may affect Business Associate's use or disclosure of Protected Health
Information.
- Covered Entity shall notify Business Associate of
any restriction to the use or disclosure of Protected Health
Information 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 Protected Health Information.
Permissible Requests by Covered Entity
Covered Entity shall not request Business Associate to
use or disclose Protected Health Information in any manner that would
not be permissible under the Privacy Rule if done by Covered Entity.
[Include an exception if the Business Associate will use or disclose
protected health information for, and the contract includes provisions
for, data aggregation or management and administrative activities of
Business Associate].
Term and Termination
- Term. The Term of this
Agreement shall be effective as of [Insert Effective Date], and shall
terminate when all of the Protected Health Information 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 Protected Health Information, protections are extended to such
information, in accordance with the termination provisions in this
Section. [Term may differ.]
- 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
[and the _________ Agreement/ sections ____ of the ______________
Agreement] if Business Associate does not cure the breach or end the
violation within the time specified by Covered Entity;
- Immediately terminate this Agreement [and the
_________ Agreement/ sections ____ of the ______________ 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.
[Bracketed language in this provision may be
necessary if there is an underlying services agreement. Also,
opportunity to cure is permitted, but not required by the Privacy
Rule.]
- 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 Protected Health
Information received from Covered Entity, or created or received by
Business Associate on behalf of Covered Entity. This provision shall
apply to Protected Health Information that is in the possession of
subcontractors or agents of Business Associate. Business Associate
shall retain no copies of the Protected Health Information.
- In the event that Business Associate determines
that returning or destroying the Protected Health Information is
infeasible, Business Associate shall provide to Covered Entity
notification of the conditions that make return or destruction
infeasible. Upon [Insert negotiated terms] that return or
destruction of Protected Health Information is infeasible, Business
Associate shall extend the protections of this Agreement to such
Protected Health Information and limit further uses and disclosures
of such Protected Health Information to those purposes that make the
return or destruction infeasible, for so long as Business Associate
maintains such Protected Health Information.
Miscellaneous
- Regulatory References.
A reference in this Agreement to a section in the Privacy Rule means
the section as in effect or as amended.
- Amendment. The Parties
agree to take such action as is necessary to amend this Agreement from
time to time as is necessary for Covered Entity to comply with the
requirements of the Privacy Rule and the Health Insurance Portability
and Accountability Act of 1996, Pub. L. No. 104-191.
- Survival. The
respective rights and obligations of Business Associate under Section
[Insert Section Number Related to "Effect of Termination"] of this
Agreement shall survive the termination of this Agreement.
- Interpretation. Any
ambiguity in this Agreement shall be resolved to permit Covered Entity
to comply with the Privacy Rule.
1 Words or phrases contained in brackets are intended as
either optional language or as instructions to the users of these sample
provisions and are not intended to be included in the contractual
provisions.
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