Office of HIPAA Privacy and Security

Business Associates

A business associate refers to any outside party (i.e., not a member of the University's workforce) that:

  1. receives protected health information from the covered entity, another business associate of the covered entity or OHCA, or the OHCA in connection with the provision of accounting, accreditation, actuarial, administrative, consulting, data aggregation, management, financial or legal services to or for the covered entity or OHCA; or
  2. uses or discloses protected health information in connection with the performance of a function or activity on behalf of the covered entity or OHCA.

A Business Associate contract is required before the University can share its PHI with any outside party/vendor.

Please complete the form below so that we may confirm the need for a Business Associate Contract and begin the process if necessary. All fields are required and you must click on the Submit button at the end. This form should only be completed by a member of the University's workforce.

Please also email or fax a copy of the underlying agreement between this vendor and the University to our office at 305-243-7487. If you require any assistance with this form, please contact us.

Business Associate Registration Form

Required fields.

To be completed by the University department

Department Name:
Division Name or other Dept.:
Department Contact Person:
Department Contact Title:
Department Contact Email:
Telephone:
Fax:

Vendor/Business Associate Information
Vendor Name:
Contact Person:
Contact Title:
Contact Email:
Address:
City:
State:
Postal Code:
Country:
Telephone:
Fax:
Product/Service Provided to the University:
Type of PHI Disclosure:
Purpose of Disclosure:
Comments: