SAMPLE BUSINESS
ASSOCIATES AGREEMENT (ON YOUR LETTERHEAD):
Business Associate Agreement
Agreement made on this date,
(Insert Date) by and between (Company Name) and BudgetShred, Inc. Both parties
being desirous of being in compliance with the HIPAA Regulations recognize
BudgetShred, Inc. is a Business Associate as defined by the HIPAA Regulations. BudgetShred, Inc. will receive PHI (Protected Health
Information) from (Company Name) for the sole purpose of disposal of this
material by shredding in conformity with the HIPAA Regulation.
Accurate Document
Destruction, Inc., will issue a Certificate of Destruction in the format
recommended by HIPAA.
In the case of any
electronically stored confidential material we may supply BudgetShred, Inc.
with, they must employ the recommended HIPAA process of magnetically distorting
or shredding of the stored information and rendering it non-retrievable.
(Company Name) has done due
diligence in choosing BudgetShred, Inc. as a Business Associate in relying on
the information presented to us by BudgetShred, Inc., and have verified the
information given.
Agreed and Accepted By
________________________
On behalf of (firm's name)
Agreed and Accepted By
________________________
Michael Rogers
General Manager
BudgetShred, Inc.
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