HIPAA Agreement Form
This Agreement ("Agreement") is entered into as of [Month Day, Year], by [Your Company Name]("Covered Entity") a company with its principal place of business located at [Your Company Address] and Client Name]("Business Associate") an individual with its main residence located at [Client Address]. This Agreement ensures compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its regulations regarding the protection of Protected Health Information (PHI).
I. Responsibilities of the Business Associate
The Business Associate agrees to use or disclose PHI only as permitted by this Agreement or required by law. Return or destroy all PHI upon termination of this Agreement, unless otherwise required by law.
II. Permitted Uses and Disclosures
The Business Associate may use or disclose PHI to perform services outlined in the agreement with the Covered Entity. For proper management and administrative purposes, provided the disclosures are required by law or with prior written consent from the Covered Entity.
III. Term and Termination
This Agreement shall remain in effect as long as the Business Associate provides services involving PHI or until terminated by either party with [Timeframe]written notice. Upon termination, the Business Associate must return or destroy all PHI unless infeasible.
IV. Acknowledgment and Signature
By signing below, the parties acknowledge and agree to abide by the terms of this Agreement.
Covered Entity:
Name:
Date:
Business Associate:
Name:
Date:
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