You can open the HIPAA Confidentiality Agreement Template in multiple formats, including PDF, Word, and Google Docs.
HIPAA Confidentiality Agreement Template Printable | Editable FormSample
[Name of the Covered Entity]
[Entity’s ID]
[Entity’s Address]
[Entity’s Phone]
[Entity’s Email]
[Name of the Business Associate]
[Associate’s ID]
[Associate’s Address]
This agreement is made to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) regarding the use and disclosure of Protected Health Information (PHI) starting on [Effective Date].
For purposes of this agreement, Protected Health Information (PHI) includes all individually identifiable health information in any form.
The Business Associate agrees to use PHI only for the purposes outlined in this agreement, and shall not disclose PHI without the explicit consent of the Covered Entity.
The Business Associate shall implement appropriate safeguards to protect against any anticipated threats to the security of PHI, including administrative, physical, and technical safeguards.
In the event of a breach of unsecured PHI, the Business Associate agrees to notify the Covered Entity promptly and in compliance with the HIPAA breach notification requirements.
The Covered Entity reserves the right to terminate this agreement if the Business Associate fails to comply with any provision of this agreement, including maintaining confidentiality of PHI.
Upon termination of this agreement, the Business Associate shall return or destroy all PHI received from the Covered Entity, and shall not retain copies of such information.
[Signature of the Covered Entity Representative]
[Name of the Covered Entity Representative]
[Signature of the Business Associate Representative]
[Name of the Business Associate Representative]
[Name of the Covered Entity]
[Entity’s ID]
[Entity’s Address]
[Entity’s Phone]
[Entity’s Email]
[Name of the Business Associate]
[Associate’s ID]
[Associate’s Address]
This HIPAA Confidentiality Agreement sets forth mandated guidelines for the use and protection of PHI in accordance with the HIPAA regulations, effective as of [Effective Date].
The Business Associate must comply with all HIPAA rules as it relates to PHI and must protect its confidentiality with utmost diligence.
The Business Associate may access and use PHI only to perform its obligations as described in this agreement and must limit access to only those employees requiring access to fulfill such obligations.
The Covered Entity retains the right to conduct audits and inspections of the Business Associate’s records and practices, related to its compliance with this agreement.
The Business Associate agrees to indemnify and hold harmless the Covered Entity from any claims, losses, or damages resulting from the Business Associate’s violation of this agreement or HIPAA.
The Business Associate agrees that any subcontractors will also comply with the terms of this agreement and will adhere to HIPAA requirements.
This agreement is effective as of [Effective Date] and shall remain in effect until terminated by either party, in accordance with termination provisions herein.
[Signature of the Covered Entity Representative]
[Name of the Covered Entity Representative]
[Signature of the Business Associate Representative]
[Name of the Business Associate Representative]
Form
Please complete the form below to create the HIPAA Confidentiality Agreement Template. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. HIPAA Confidentiality Agreement Template 1. Covered Entity Information 2. Business Associate Information 3. Agreement Purpose 4. Definition of PHI 5. Responsibilities of Covered Entity 6. Responsibilities of Business Associate 7. Use and Disclosure of PHI 8. Breach Notification 9. Termination Clause 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
HIPAA Confidentiality Agreement Template Printable | Editable FormPrintable
