Please note that the attached Business Associate Agreement has been updated as
of August 12, 2013 to reflect the new requirements set forth in the Health
Information Technology for Economic & Clinical Health Act ("HITECH"), Subtitle
D-Privacy (§§13400-13424), as part of the American Recovery and Reinvestment Act
of 2009, and as amended.
It is recommended
that all entities having a business relationship with MedPro RRG Risk Retention
Group ("MedPro RRG") complete this updated version and retain a copy for their
Instructions for Completing HIPAA Business Associate
- Please be sure to have your
MedPro RRG Policy Number available before you begin.
- In the first box,
enter initials indicating you understand you are entering into a legally binding
- If you are a doctor or with a group of doctors
enter your six digit MedPro RRG policy number as your signature. If you are
signing on behalf of a hospital or for any other reason do not have an
individual policy number, please enter your first and last name. By
signing this agreement, you represent that you are authorized to sign on behalf
of the individual, partnership, professional corporation, hospital or other
entity on whose behalf this agreement is made.
- Validate your
electronic signature by entering the requested contact information.
Before clicking "I Accept," please print out a copy of the fully
- After completing and printing the
addendum, click "I Accept".
- You Are Finished- It's That
Please save or print this form as
confirmation that you entered into this agreement with MedPro RRG Risk Retention
Group, by and through its Attorney-in-Fact, MedPro Risk Retention Services, Inc.
Please note: Due to the large number of requests, this
electronic format is the exclusive method to enter into a Business Associate
Agreement with MedPro RRG. Paper submissions of this form or alternative forms
will be returned.
Thank You For Using MedPro RRG’s Electronic
HIPAA Business Associate Addendum!
This agreement ("Agreement") is effective
upon its execution and delivery to MedPro RRG Risk Retention Group (referred to
as "Business Associate" hereafter), as further indicated below, by and between
the Business Associate, by and through is Attorney-in-Fact, MedPro Risk
Retention Services, Inc., and the undersigned health care provider or other
services provider (referred to as "Provider" hereafter).
Provider and Business Associate mutually agree to the terms of this Agreement to
comply with the requirements of the Standards for Security and Privacy of
Individually Identifiable Information (the "Security and Privacy Regulations"),
as applicable, under the Health Insurance Portability and Accountability Act of
1996 ("HIPAA"), as amended, as well as with the Health Information Technology
for Economic & Clinical Health Act ("HITECH"), Subtitle D-Privacy
(§§13400-13424), as part of the American Recovery and Reinvestment Act of 2009,
Business Associate and Provider have a business relationship
such that Provider may be deemed to be a covered entity, and in conducting such
activities on behalf of Provider, Business Associate may be deemed a business
associate of Provider.
Provider wishes to disclose certain information
to Business Associate pursuant to the terms of this Agreement, some of which may
constitute Protected Health Information ("PHI") (as defined below).
Provider and Business Associate intend to protect the privacy and provide for
the security of PHI disclosed to Business Associate pursuant to this Agreement
in compliance with the HIPAA Security and Privacy Regulations and HITECH.
HIPAA Security and Privacy Regulations and HITECH require Provider to enter into
a contract containing specific requirements with Business Associate prior to the
disclosure of PHI, as set forth in this Agreement.
The following terms used in this Agreement shall have the same meaning as those
terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set,
Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of
Privacy Practices, Protected Health Information, Required By Law, Secretary,
Security Incident, Subcontractor, Unsecured Protected Health Information, and
- Business Associate. "Business Associate"
shall generally have the same meaning as the term "business associate" at 45 CFR
160.103, and in reference to the party to this agreement, shall mean MedPro RRG
Risk Retention Group, by and through its Attorney-in-Fact, MedPro Risk Retention
- Covered Entity. "Covered
Entity" shall generally have the same meaning as the term "covered entity" at 45
- HIPAA Rules. "HIPAA Rules"
shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at
45 CFR Part 160 and Part 164.
B. 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;
- Use appropriate
safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to
electronic protected health information, to prevent use or disclosure of
protected health information other than as provided for by the Agreement;
Report to Provider any use or disclosure of protected health information not
provided for by the Agreement of which it becomes aware, including breaches of
unsecured protected health information as required at 45 CFR 164.410, and any
security incident of which it becomes aware;
- In accordance with 45 CFR
164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any
subcontractors that create, receive, maintain, or transmit protected health
information on behalf of Business Associate agree to the same restrictions,
conditions, and requirements that apply to Business Associate with respect to
- Make available protected health information in a
designated record set to Provider as necessary to satisfy Provider’s
obligations, if any, under 45 CFR 164.524;
- Make any amendment(s) to
protected health information in a designated record set as directed or agreed to
by Provider pursuant to 45 CFR 164.526, or take other measures as necessary to
satisfy Provider’s obligations, if any, under 45 CFR 164.526;
and make available the information required to provide an accounting of
disclosures to the Provider as necessary to satisfy Provider’s obligations, if
any, under 45 CFR 164.528;
- To the extent Business Associate is to
carry out one or more of Provider’s obligation(s) under Subpart E of 45 CFR Part
164, comply with the requirements of Subpart E that apply to Provider in the
performance of such obligation(s); and
- Make its internal practices,
books, and records available to the Secretary for purposes of determining
compliance with the HIPAA Rules.
C. Permitted Uses and
Disclosures by Business Associate
Business Associate may only use or disclose protected health information as
necessary to perform any services necessary or required as Provider’s insurance
- Business Associate may use or disclose protected health
information as required by law.
- Business Associate agrees to make uses
and disclosures and requests for protected health information subject to the
following minimum necessary requirements: as necessary or required in order to
provide Provider’s insurance.
- Business Associate may not use or
disclose protected health information in a manner that would violate Subpart E
of 45 CFR Part 164 if done by Provider, except with regards to the data
aggregation, management, administration and legal responsibilities of the
- Business Associate may use protected health
information for the Business Associate’s proper management and administration or
to carry out the legal responsibilities of the Business Associate.
Business Associate may disclose protected health information for the proper
management and administration of Business Associate or to carry out the legal
responsibilities of the Business Associate, provided the disclosures are
required by law, or Business Associate obtains reasonable assurances from the
person to whom the information is disclosed that the information will remain
confidential and used or further disclosed only as required by law or for the
purposes for which it was disclosed to the person, and the person notifies
Business Associate of any instances of which it is aware in which the
confidentiality of the information has been breached.
Associate may provide data aggregation services relating to the health care
operations of Provider.
D. Provisions for Provider to Inform Business Associate of Privacy Practices
Provider shall notify Business Associate of:
- any limitation(s) in Provider’s notice of privacy
practices under 45 CFR 164.520;
- of any changes in, or revocation of, the permission by an individual to use or
disclose his or her protected health information; or,
- any restriction on the use or disclosure of protected health information that
Provider has agreed to or is required to abide by under 45 CFR 164.522,
to the extent that Business Associate’s use or disclosure of protected health information will be affected.
E. Term and Termination
Term. This Agreement shall continue in force so long
as any underlying contract between the Provider and Business Associate remains
- Termination for Cause. The Provider
shall provide written notice if it determines that Business Associate has
breached any material provision of this Agreement. The written notice must
contain the facts necessary for Business Associate to evaluate and cure the
alleged breach. If the breach is not cured within 30 days, the Provider may
immediately terminate this Agreement.
of Business Associate Upon Termination. Upon termination of this
Agreement for any reason, Business Associate, with respect to protected health
information received from Provider, or created, maintained, or received by
Business Associate on behalf of Provider, shall:
- Retain only that
protected health information which is necessary for Business Associate to
continue its proper management and administration or to carry out its legal
- Destroy the remaining protected health information
that Business Associate still maintains in any form;
- Continue to
use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with
respect to electronic protected health information to prevent use or disclosure
of the protected health information, other than as provided for in this Section,
for as long as Business Associate retains the protected health information;
Not use or disclose the protected health information retained by Business
Associate other than for the purposes for which such protected health
information was retained and subject to the same conditions set out at above
which applied prior to termination; and
- Destroy the protected
health information retained by Business Associate when it is no longer needed by
Business Associate for its proper management and administration or to carry out
its legal responsibilities.
The obligations of Business Associate under this Section shall
survive the termination of this Agreement.
Regulatory References. A reference in this Agreement
to a section in the HIPAA Rules 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
compliance with the requirements of the HIPAA Rules and any other applicable
- Interpretation. Any ambiguity in
this Agreement shall be interpreted to permit compliance with the HIPAA Rules.
IN WITNESS WHEREOF, the Provider and the Business Associate execute this
Business Associate Agreement to be effective as of the date signed and submitted
by the Provider as indicated below:Signed:
MedPro RRG Risk Retention Group
Angela M. Adams
MedPro Risk Retention Services, Inc.
Attorney-in-Fact for MedPro RRG Risk Retention Group,
5814 Reed Road
Fort Wayne, Indiana 46835
BY TYPING YOUR INITIALS IN THE BOX AT THE END OF THIS SENTENCE YOU ACKNOWLEGE
THAT IT IS YOUR INTENT THAT THE POLICY NUMBER TYPED IN THE SIGNATURE BOX BELOW
WILL SERVE AS YOUR SIGNATURE FOR THE PURPOSE OF THIS BUSINESS ASSOCIATE
AGREEMENT AND THAT YOU AGREE TO CONDUCT THIS TRANSACTION ELECTRONICALLY.