Business Associate Agreement
Pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 and any amendments thereto (hereinafter “HIPAA”); and the HIPAA Security and Privacy rule, 45 CFR Parts 160 and 164, and any amendments thereto (hereinafter the “HIPAA Security and Privacy Rule”) as well as other applicable federal and state privacy and confidentiality rules, the following parties (referred to jointly as “the parties”) wish to enter into this agreement (“Agreement”) to address the requirements of the HIPAA Security and Privacy Rule with respect to “business associates,” as that term is defined in the HIPAA Security and Privacy Rule.
Tom Lutz & Associates / Lutz Therapy
WHEREAS, Business Associate acknowledges that it is required to establish and implement appropriate safeguards (including certain administrative requirements) for “Protected Health Information” (“PHI”) as defined by HIPAA in any form or medium, including electronic, the Business Associate may create, receive, maintain, transmit, use, or disclose in connection with certain functions, activities, or services (collectively “services”) to be provided by Business Associate to or on behalf of Covered Entity;
WHEREAS, the services to be provided by Business Associate are identified in a separate agreement (“Service Agreement”) between Employer or Plan Sponsor and Business Associate and include, but are not limited to:
WHEREAS, The Parties acknowledge and agree that Business Associate may create, receive, maintain, transmit, use or disclose PHI if within the scope of, and necessary to achieve, the obligations and responsibilities of the Business Associate in performing on behalf of, or providing services to, the Covered Entity pursuant to the Services Agreement;
NOW, THEREFORE, in connection with Business Associate’s creation, receipt, maintenance, transmission, use or disclosure of PHI as a Business Associate of the Covered Entity, Business Associate and Covered Entity agree as follows:
Name / Title:
Covered Entity: Tom Lutz & Associates/Lutz TherapyAuthorized Agent: Anne Hewitt, OwnerBusiness Associate: Representative:
Leave this empty:
Signed by Anne Hewitt
Signed On: April 24, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Business Associate Agreement
Agree & Sign