QUALIFiED SERVICE ORGANIZATION



QUALIFIED SERVICE ORGANIZATION /

BUSINESS ASSOCIATE

AGREEMENT

(Name of business providing service) ___________________________ and (Name of the alcohol/drug agency) ___________________________ hereby enter into an agreement whereby (Name of business providing service) ___________________________ agrees to provide __________________________ services [Choose one: to (Name of the alcohol/drug agency) OR to the patients of (Name of the alcohol/drug agency)].

Furthermore, (Name of business providing service) ___________________________

(1) Acknowledges that in receiving, transmitting, transporting, storing, processing, or otherwise dealing with any information (“protected information”) received from (Name of the alcohol/drug agency) ____________________________ identifying or otherwise relating to the patients in (Name of the alcohol/drug agency) ___________________________, it is fully bound by the provisions of federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR. Part 2; and the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR. Parts 142, 160 and 164, and may not use or disclose the information except as permitted or required by this Agreement or by law;

(2) Agrees to resist any efforts in judicial proceedings to obtain access to the protected information except as expressly provided for in the regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR. Part 2.

(3) Agrees to use appropriate safeguards, to prevent the unauthorized use or disclosure of the protected information;

(4) Agrees to report to (Name of the alcohol/drug agency) ___________________________ in writing within one business day, any use or disclosure of the protected information not provided for by this Agreement of which it becomes aware.

(5) Agrees to ensure that any protected information received from (Name of the alcohol/drug agency) ___________________________ will not be redisclosed to any other agency or subcontractor who provides services to (Name of business providing service) ___________________________.

Note: HIPAA regulations allow (Name of business providing service) ___________________________ to share protected information created or received by (Name of business providing service) ___________________________with other agencies or subcontractors, to whom (Name of business providing service) ___________________________provides the protected information received from (Name of alcohol/drug treatment agency) ___________________________, provided the other agency or subcontractor agrees to the same restrictions and conditions that apply through this agreement to (Name of business providing service) ___________________________ with respect to such information. Even though HIPAA regulations allow for the redisclosure described above, such redisclosure would violate the more stringent general rule of 42 CFR Part 2 prohibiting redisclosure.

6) Agrees to provide access to the protected information within one business day at the request of (Name of the alcohol/drug agency) ___________________________ or to an individual as directed by (Name of the alcohol/drug agency) ___________________________ in order to meet the requirements of 45 CFR. § 164.524 which provides patients with the right to access and copy their own protected information.

(7) Agrees to make any amendments to the protected information within one business dayas directed or agreed to by (Name of the alcohol/drug agency) ___________________________ pursuant to 45 CFR. § 164.526.

(8) Agrees to make available within one business day its internal practices, books, and records, including policies and procedures, relating to the use and disclosure of protected information received from (Name of the alcohol/drug agency) ___________________________ or created or received by (Name of business providing service) ___________________________ on behalf of (Name of the alcohol/drug agency) ___________________________, or to the Secretary of the Department of Health and Human Services for purposes of the Secretary determining the Program’s compliance with HIPAA

(9) Agrees to document, in written form by letter or fax within one business day, disclosures of protected information, and information related to such disclosures, as would be required for the Program to respond to a request by an individual for an accounting of disclosures in accordance with 45 CFR § 1 64.528

(10) Agrees to provide, within one business day by written letter or fax, to (Name of the alcohol/drug agency) ___________________________ or to an individual, information in accordance with paragraph (9) of this agreement to permit (Name of the alcohol/drug agency) ___________________________ to respond to a request by an individual for an accounting of disclosures in accordance with 45 CFR. § 164.528

Termination

(1) (Name of the alcohol/drug agency) ___________________________ may terminate this agreement if it determines that (Name of business providing service) ___________________________ had violated any material term;

(2) Upon termination of this agreement for any reason, (Name of business providing service) ___________________________ shall return or destroy all protected information received from the Program, or created or received by (Name of business providing service) ___________________________ on behalf of (Name of the alcohol/drug agency)___________________________. This provision shall apply to protected information that is in the possession of subcontractors or agents of (Name of business providing service) ___________________________, if such information has been redisclosed to subcontractors or agents of (Name of business providing service___________________________). (Name of business providing service) ___________________________ shall retain no copies of the protected information.

(3) In the event that (Name of business providing service) ___________________________ determines that returning or destroying the protected information is infeasible, (Name of business providing service) ___________________________ shall notify (Name of the alcohol/drug agency) ___________________________, in writing within one business day of the request, of the conditions that make return or destruction infeasible. Upon notification that the return or destruction of the protected information is infeasible, (Name of business providing service) ___________________________ shall extend the protections of this Agreement to such protected information and limit further uses and disclosures of the information to those purposes that make the return or destruction infeasible, for so long as (Name of business providing service) ___________________________ maintains the information.

Executed this _____ day of___________________, 20___.

(Signature:) (Signature:)

_______________________________ ________________________________

(Title of person authorized to sign) (Title of person authorized to sign)

_______________________________ ________________________________

(Name of business providing service) (Name of the alcohol/drug agency)

[address] [address]

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