Fillable Form 1: BUSINESS ASSOCIATE PRIVACY AGREEMENT A. Definitions (Dickerson Insurance Services)

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Form 1: BUSINESS ASSOCIATE PRIVACY AGREEMENT A. Definitions (Dickerson Insurance Services)

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This Business Associate Privacy Agreement (this “Agreement”), effective , is entered into by and between CHOICE Administrators
®
, Inc. (and its
Affiliates, as defined herein) (collectively, the “Company”) and the entity identified on the signatory page (“Broker”), (collectively, the “Parties”). This Agreement is
drafted for the express purpose of complying with the privacy requirements of the California Insurance Information and Privacy Protection Act (CIC 791 et
seq.,“IIPPA”), the Gramm-Leach-Bliley Act (15 U.S.C. §§ 1501 et seq., the “GLBA”) and regulations adopted by the California Department of Insurance to implement IIPPA
and the GLBA (10 C.C.R. §§ 2689.1 et seq., the “IIPPA Privacy Regulations”), the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and regulations
adopted by the U.S. Department of Health and Human Services to implement HIPAA (45 CFR Parts 160-64, the “HIPAA Privacy Regulations”) to ensure the integrity and
confidentiality of individually identifiable personal and health information that Broker may collect, create for or receive from the Company (collectively, the “Privacy Rule”).
Additional terms and conditions in accordance with local privacy ordinances shall be set forth in an Addendum. The term “Privacy Rule” also includes local privacy ordinances.
CA 0125B 10/2013(1 of 4)
BUSINESS ASSOCIATE PRIVACY AGREEMENT
(Continued)
Whereas, Company is a Business Associate to various health plans that are Covered Entities; and
Whereas, As a Business Associate, Company is obligated to safeguard the privacy and security of Protected Health Information received by or created for or on behalf of
such covered Entities; and
Whereas, Company has engaged Broker to perform certain functions for and on behalf of Company and/or such a Covered Entity pursuant to which Broker shall
receive certain Protected Health Information of such a Covered Entity; and
Whereas, Company desires to secure Broker’s assurances that it will safeguard the privacy and security of such Protected Health Information and take other actions in
order to assist Company in meeting its obligations to such Covered Entities and as a Business Associate under HIPAA.
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B. Privacy of Personal and Health Information
1. Permitted Uses and Disclosures. Broker is permitted or required to use or disclose Health Information or Personal and Health Information it collects, creates for or
receives from the Company only as follows:
Functions and Activities on the Company’s Behalf. Broker is permitted to use and disclose the minimum necessary Health Information or Personal and Health Information it
collects, creates for or receives from the Company in order to provide services to the Company, any Covered Entity for which the Company and/or Broker are Business
Associates, or another Business Associate of such a Covered Entity.3.5
Broker’s Operations. Broker may use and disclose the minimum necessary Health Information or Personal and Health Information it collects, creates for or receives
from the Company as necessary in order to perform Broker’s proper management and administration, or to carry out Broker’s legal responsibilities. If Broker discloses
such Health Information or Personal and Health Information to an agent, a subcontractor or other third party, then Broker shall obtain reasonable assurances from the
agent, subcontractor or other third party to which Broker discloses such Health Information or Personal and Health Information that agent, subcontractor or other third
party shall: (i) hold such Health Information or Personal and Health Information in confidence and use or further disclose it only for the purposes for which Broker
disclosed it to the agent, subcontractor or other third party or as required by law; and (ii) notify Broker (who shall in turn promptly notify the Company) of any instances
of which the agent, subcontractor or other third party becomes aware that the confidentiality of such Health Information or Personal and Health Information was
breached.
“Affiliate” or “Affiliated” means a person that directly, or indirectly through one or more intermediaries, controls, is controlled by or is under common control with
another person.
“Breach” (with respect to Unsecured Health Information) shall have the meaning set forth in 45 C.F.R. § 164.402, as amended from time to time, and currently
means the acquisition, access, use or disclosure of protected health information in a manner not permitted under the Privacy or Security Standards and which
compromises the security or privacy of the Health Information.
“Business Associate” means an individual or entity that performs a function or activity on behalf of, or provides a service to a Covered Entity (as defined herein),
that involves the collection, creation, use or disclosure of Personal and Health Information.
“Covered Entity” means a health plan, health care clearinghouse or a health care provider who transmits any health information in electronic form in connection
with a transaction covered under the HIPAA Privacy Regulations.
“De-Identify” or “De-Identification” means Health Information that does not identify an individual and with respect to which there is no reasonable basis to believe
that such information can be used to identify an individual.
“Designated Record Set” means a group of records maintained by or for a Covered Entity comprising the enrollment, payment, claims adjudication, and case or
medical management record systems maintained by or for a Covered Entity or Business Associate of the Covered Entity or used, in whole or in part, by or for the
Covered Entity to make decisions about individuals. For purposes of this Section, the term “record” includes any item, collection, or grouping of information that
contains Personal and Health Information and is maintained, collected, used, or disseminated by or for a Covered Entity or the Company.
“Electronic Health Information” means Health Information that is transmitted or maintained in electronic media.
“Electronic Media” means:
(i) Electronic storage media including memory devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk,
optical disk, or digital memory card; or (ii) Transmission media used to exchange information already in electronic storage media. Transmission media include, for example,
the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private
networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via
telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission.
“Health Information” means “Protected Health Information” as this term is defined under the HIPAA Privacy Regulations, and includes any information in
possession of or derived from a physician or other provider of health care or a health care service plan regarding an individual’s medical history, mental or physical
condition or treatment, as well as information related to the past, present or future payment for the provision of healthcare.
“Limited Data Set” means Health Information that excludes the following direct identifiers of the individuals or of relatives, employers or household members of the
individual: (i) names; (ii) postal address information, other than town or city, State and ZIP Code; (iii) telephone numbers; (iv) fax numbers; (v) electronic mail addresses;
(vi) social security numbers; (vii) medical record numbers; (viii) health plan beneficiary numbers; (ix) account numbers; (x) certificate/license numbers; (xi) vehicle identifiers
and serial numbers, including license plate numbers; (xii) device identifiers and serial numbers; (xiii) Web Universal Resource Locators (URLs); (xiv) Internet Protocol (IP)
address numbers; (xv) biometric identifiers, including finger and voice prints; and (xvi) full face photographic images and any comparable images.
“Personal and Health Information” means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made
about an individual’s character, habits, avocations, finances, occupation, general reputation, credit, health or any other personal characteristics. Individually identifiable
information includes the individual’s name, address, electronic mail address, telephone number, social security number and other information, alone or in combination with
other publicly available information, which reveals the individual’s identity. Personal information includes the individual’s nonpublic personal financial information.
“Security Standards” shall mean the Security Standards for the Protection of Electronic Health Information, 45 CFR Part 160 and Part 164, Subparts A and C.
“Unsecured Health Information” shall mean unsecured PHI as set forth in 45 CFR § 164.402, as amended from time to time, and currently means Health
Information that has not been rendered unusable, unreadable or indecipherable to unauthorized individuals through the use of a technology or methodology
specified by the Secretary of Health and Human Services.
A. Definitions
a)
b)
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(2 of 4) CA 0125B 10/2013
(continued)
(Continued)
2.
3.
b)
c)
5.
6.
D.
Breach
1.
2.
a)
b)
Obligations upon Termination. Upon termination, cancellation, expiration or other conclusion of this Agreement or any other agreements for any reason, Broker shall
comply with applicable Privacy Rule requirements regarding the return or destruction of Health Information or Personal and Health Information.
Continuing Privacy Obligation. Broker’s obligation to protect the privacy of the Health Information or Personal and Health Information shall be continuous and survive
termination, cancellation, expiration or other conclusion of this Agreement.
Prohibition on Unauthorized Use or Disclosure. Broker shall neither use nor disclose Health Information or Personal and Health Information it collects, creates for or
receives from the Company, except as permitted or required by this Agreement, or as permitted or required by law.
Compliance with the Company’s Confidentiality/Privacy Policies. Broker shall comply with the Company’s Privacy Statement included at the end of this document and
other Confidentiality, Privacy, and Security Policies the company may make available to the broker over the term of this agreement to meet applicable legal requirements.
De-Identification of Information/Creation of Limited Data Set. Broker shall not De-Identify Health Information it creates or receives for or from the Company, and shall not
use or disclose such de-identified information, unless such de-identification is expressly permitted under the terms and conditions of this Agreement for services to be provided
by Broker to the Company related to the Company’s activities for purposes of “treatment,” “payment” or “health care operations,” as those terms are defined under the HIPAA
Privacy Regulations. Broker further agrees that it will not create a Limited Data Set using Health Information it creates or receives for or from the Company, nor use or
disclose such Limited Data Set unless: (i) such creation, use or disclosure is expressly permitted under the terms and conditions of this Agreement; and (ii) such creation,
use or disclosure is for services provided by Broker that relate to the Company’s activities for purposes of “payment” or “health care operations,” as those terms are defined
under the HIPAA Privacy Regulations.
Information Safeguards. Broker shall develop, implement, maintain and use appropriate administrative, technical and physical safeguards, in compliance with applicable state
and federal laws, to preserve the confidentiality of and to prevent unauthorized disclosures of Health Information or Personal and Health Information collected, created or
received for or from the Company. Broker shall document and keep such safeguards current and, upon the Company’s reasonable request, shall provide the Company with a
copy of policies and procedures related to such safeguards.
C. Personal and Health Information Access, Amendment and Disclosures
1.
2.
Access. Broker shall, upon the Company’s reasonable request permit, within ten (10) business days of receipt of request, an individual (or the individual’s personal
representative) to inspect and obtain copies of any Health Information or Personal and Health Information about the individual which Broker collected, created or received
for or from the Company and that is in Broker’s custody or control.
Amendment. Broker shall, upon receipt of notice from the Company, promptly amend or permit the Company access to amend any portion of an individual’s Health
Information or Personal and Health Information which Broker collected, created or received for or from the Company and that is in Broker’s custody or control.
Disclosures. Broker shall document each disclosure it makes of an individual’s Health Information or Personal and Health Information to a third party. Moreover, for
purposes of this Section, “disclosure” includes: 1) any legal disclosure; 2) any illegal, inadvertent, wrongful, or negligent disclosure; and 3) any instance in which access was
provided to an unauthorized third party to an individual’s Health Information or Personal and Health Information. For the purposes of this Agreement, “legal disclosure”
includes, but is not limited, any disclosures to law enforcement or other governmental authority pursuant to law and in response to a facially valid administrative or judicial
order, such as a search warrant or subpoena.
3.
a)
Disclosure
Reporting.4.
Legal. In a timely manner but not later than 30 days from the date of the disclosure, Brokers shall forward to the Company a report of such disclosures, as required by 45
CFR § 164.528; however, this requirement shall not apply if Broker has not made any such disclosures. Such report shall include the applicable individual’s name, the
person to whom the Health Information or Personal and Health Information was disclosed, what was disclosed, why the information was disclosed, and the date of such
disclosure.
Illegal, Inadvertent or Wrongful Disclosure. Broker shall report to the Company any use or disclosure of Health Information or Personal and Health Information not
permitted by this Agreement or that would be in violation of the Privacy Rule if made by Company. Business Associate shall make the report to the Company not more
than twenty-four (24) hours after Broker learns of such non-permitted use or disclosure. Broker shall report such disclosure in accordance with Section D of this
Agreement.
Termination of Agreement. Upon termination of this Agreement, Broker shall provide to the Company one final report of any and all disclosures made of all
individuals’ Health Information or Personal and Health Information.
Inspection of Books and Records. Broker shall make its internal practices, books and records, relating to its use and disclosure of the Personal and Health Information it
collects, creates or receives for or from the Company, available to the U.S. Department of Health and Human Services or to the California Insurance Commission to determine
the Company’s compliance, as a Business Associate, with the provisions of the HIPAA Privacy Regulations or the IIPPA Privacy Regulations, whichever is applicable.
Designated Record Set. Broker agrees that all Health Information or Personal and Health Information received by or created for the Company shall be included in an
individual’s Designated Record Set. Broker shall maintain such Designated Record Set with respect to services provided to an individual under this Agreement, and shall allow
such individual to access the Designated Record Set as provided in the HIPAA Privacy Regulations.
Generally In furtherance of Broker’s obligation under Sections C.3. and C.4 above, Broker Business Associate shall, within five (5) days of becoming aware of a Breach of
Unsecured PHI or any other disclosure of protected health information in violation of this Agreement by Broker Business Associate, its officers, directors, employees,
contractors or agents or by a third party to which Broker Business Associate disclosed protected health information pursuant to Broker Business Associate Agreement, report
any such Breach or disclosure to the Company. Such notification shall include, to the extent possible, the identification of each individual whose protected health information
has been, or is reasonably believed by Broker Business Associate to have been, accessed, acquired, used, or disclosed during the Breach. In addition, Broker Business
Associate shall provide Company with the following information, to the extent available at the time initial notice to Company is provided, or promptly thereafter as such
information becomes available:
•
A brief description of what happened, including the date of the Breach or wrongful disclosure and the date of discovery
•
A description of the type of protected health information that was involved (e.g., name, Social Security Number, procedure, diagnosis, treatment, etc.)
•
The steps that BROKER BUSINESS ASSOCIATE recommends that the individual should take to protect himself or herself
•
A brief description of the steps that BROKER BUSINESS ASSOCIATE is taking to investigate, mitigate harm, and protect against future similar breaches
• Any such other information, including a written report, as the Company may reasonably r
equest
Termination
of Agreement. This Agreement shall terminate automatically in the event that Broker ceases performing services for or on behalf of Company or in the event
that Broker otherwise ceases to be a Business Associate of either the Company or a Covered Entity with respect to whom the Company is a Business Associate. The
Company may also, in addition to other available remedies, terminate this Agreement if Business Associate has materially breached any provision(s) of this Agreement and
has failed to cure or take any actions to cure such material breach within five (5) calendar days of the Company informing Broker of such material breach. The Company shall
exercise this right to terminate by providing Broker written notice of termination, which termination shall include the reason for the termination. Any such termination shall be
effective immediately (following any applicable cure period) or at such other date specified in the Company’s notice of termination.
BUSINESS ASSOCIATE PRIVACY AGREEMENT
14631
4.
5.
(3 of 4) CA 0125B 10/2013
BUSINESS ASSOCIATE PRIVACY AGREEMENT
(continued)
Department of Insurance License # State
Phone # (including area code)
Broker #
Agency #
Date (MM/DD/YYYY)
Broker First Name
Broker Last Name
Signature
STAFF USE ONLY
Broker Choice Administrators, Inc.
By
Title
Date (MM/DD/YYYY)
John M. Word III
President
February 12, 2010
E. Security of Electronic Protected Health Information
F. General Provisions
To the extent that Broker receives, uses, creates, maintains and/or discloses any Electronic Health Information (“E-PHI”) in the course of providing services for or on behalf o
f
Company,
Broker additionally agrees: (i) to implement administrative, physical and technical Safeguards to protect the confidentiality, integrity, and availability of the E-PHI that it
creates, receives, maintains, or transmits on behalf of the Company, as required by the Security Standards; (ii) to notify the Company if the Broker becomes aware of a
security incident involving the Company’s E-PHI; and (iii) to ensure that any agent, including a subcontractor, to whom it provides such E-PHI agrees to implement reasonable
and appropriate safeguards to protect the Company’s E-PHI.
IN WITNESS WHEREOF, the Company and Broker execute this Agreement in multiple originals to be effective as of the day and year written below:
CHOICE Administrators
®
, Inc.
721 S. Parker, Suite 200
Orange, CA 92868.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Injunctive Relief. In the event that Broker breaches any material term of this Agreement, Broker agrees that the Company has a right to obtain injunctive relief to prevent
further disclosure of such Health Information or Personal and Health Information. In addition to injunctive relief, the Company may also pursue any other remedy under
applicable law or equity available to it.
Independent Relationship. None of the provisions of this Agreement are intended to create, nor will they be deemed to create any relationship between the Parties other
than that of independent parties contracting with each other as independent contractors solely for the purposes of effecting the provisions of this Agreement.
Rights of Third Parties. This Agreement is between the Company and Broker and shall not be construed, interpreted, or deemed to confer any rights whatsoever to any third
party or parties.
Assignment. Broker may not assign its respective rights and obligations under this Agreement without the prior written consent of the Company.
Indemnification and Hold Harmless. Broker shall indemnify and hold harmless the Company, and the Company’s officers, directors, employees and agents from and against
any claim, cause of action, liability, damage, cost or expense, including attorneys’ fees and court or proceeding costs, arising out of or in connection with any non-permitted
use or disclosure of Health Information or Personal and Health Information or other breach of this Agreement by Broker or any Business Associate subcontractor, agent,
representative, person or entity. This Section F.5. shall survive the termination of this Agreement.
Waiver. No change, waiver or discharge of any liability or obligation hereunder on any one or more occasions shall be deemed a waiver of performance of any continuing or
other obligation, or shall prohibit enforcement of any obligation on any other occasion.
Assistance in Litigation or Administrative Proceedings. Broker shall make itself, and any subcontractors, employees or agents assisting Broker in the performance of its
obligations under this Agreement, available to the Company, at no cost to the Company, to testify as witnesses, or otherwise, in the event of litigation or administrative
proceedings being commenced against the Company, its directors, officers or employees based upon a claimed violation of any of the provisions of the Privacy Rule or other
laws relating to security and privacy, except where Broker or its subcontractor, employee or agent is a named adverse party.
Expenses. Unless otherwise stated in this Agreement, each party shall bear its own costs and expenses related to compliance with the above provisions.
Governing Law. The laws of the United States and the State of California shall govern the interpretation, validity, performance and enforcement of this Agreement. Jurisdiction
and venue for any action under this Agreement shall be in the Superior Court for the County of Orange County in the State of California.
Headings. The headings of paragraphs contained in this Agreement are for reference purposes only and shall not affect in any way the meaning or interpretation of this
Agreement.
Interpretation. The Parties agree that any ambiguity in this Agreement will be resolved in favor of an interpretation that protects the Health Information or Personal and Health
Information and facilitates Broker’s and the Company’s compliance with applicable terms and requirements of the Privacy Rule.
Entire Agreement. This Agreement constitutes the entire agreement and understanding between the Parties with respect to the subject matter of this Agreement and supersedes
and replaces any and all prior written or verbal privacy agreements. If any provision of this Agreement conflicts with any of the provisions of the Privacy Rule and other applicable law,
the said Privacy Rule or applicable law, to the extent of such conflict, shall control. The Company’s failure to insist upon or enforce strict performance of any provision of this
Agreement shall not be construed as a waiver of any provision or right. Neither the course of conduct nor trade practice between the Parties shall act to modify any provision of this
Agreement.
Conflicts. In the event that Broker has entered into one or more agreement with the Company other than this Agreement, the terms and conditions of this Agreement shall
prevail if this Agreement conflicts with any provision of any other of the Company’s agreements.
Severability. In the event that any provision of this Agreement is held by a court of competent jurisdiction to be invalid or unenforceable, the remainder of the provisions of this
Agreement will remain in full force and effect.
Notices. All notices and notifications under this Agreement shall be sent in writing to the representatives of the Company and Broker identified below, signed by the party
providing the notice or notification.
For any notification required by or provided pursuant to this Agreement, notice should be sent to:
14631
Validate My Form
(4 of 4) CA 0125B 10/2013
PRIVACY STATEMENT
CHOICE Administrators
®
is proud to provide quality employee benefit products and services to our customers. Keeping your personal information secure and protecting your
privacy rights are important to you, and it is one of our top priorities.
This statement tells you about the information we request from our customers. It also tells you how we safeguard the personal information and protect the privacy rights of our
current and former customers.
Our Privacy Commitment to You
CHOICE Administrators will safeguard your personal information and protect the privacy rights of our customers in accordance with state and federal laws. We will accomplish this in
ways that are reasonable and consistent with sound business practices.
Protecting Your Health Information
We do not share your personal health information (such as medical questionnaires) except when necessary to conduct underwriting reviews at the time of your Employer’s initial
enrollment through CHOICE Administrators or upon an Employer requested underwriting review at a subsequent renewal. In certain circumstances, we may share your personal
health information if permitted or required by law.
CHOICE Administrators is committed to protecting the confidentiality and security of your private health information. We maintain physical, electronic, and process safeguards that
restrict unauthorized access to your personal health information. These security procedures include locked files and information system security measures such as user
passwords, data encryption or firewall technology.
CHOICE Administrators employees are required to comply with our policies and procedures to protect the confidentiality of your personal health information. Any employee who
violates our privacy policy is subject to a disciplinary process. Employee access to private information is limited on a business “need-to-know” basis such as: when necessary to
conduct underwriting reviews, or for anonymous statistical analysis.
Information About Our Customers
CHOICE Administrators receives information about you in order to provide customer service, offer new products or services, administer our products, and fulfill other legal and
regulatory requirements. We will provide you with access to this information and the ability to review, amend, correct or copy this information, if we are required to do so under state
and federal law. The methods we use to protect this information are similar to those described above to protect your health information.
The information we receive may vary by product; therefore, the examples that follow may not apply to all customers but are designed to show the general categories of
information that may be received and maintained by CHOICE Administrators:
•
•
•
Information provided by you on applications, forms, surveys and our Web sites, such as your name, address, date of birth, Social Security number, gender, marital status
and dependents.
Information provided by your employer.
Information about your transactions and experiences with CHOICE Administrators such as: products or services purchased, account balances, payment history, policy
coverage, and premiums.
Information Shared Within the Word & Brown Family of Companies
While understanding the importance of protecting your personal information, certain information will need to be shared during the normal course of business. We may disclose to the
extent permitted by law the personal information we receive about you, as described above, within the Word & Brown Family of Companies.
Information Shared With Others
We may disclose the personal information we receive, as described above, to the following types of third parties:
•
•
Other third parties as permitted or required by law, such as for compliance with a subpoena, fraud prevention, or inquiries from state or federal regulatory agencies.
Financial service companies with whom we have agreements, such as: insurance companies, insurance brokers or agents, administrators, and service providers.
We maintain written contracts with third parties to help ensure that the personal information we share about our customers is used for a legitimate business purpose.
Access and Amendment of Your Records
You have the right to access and amend your records. You may exercise this right by requesting to us in writing to access and/or amend your records. Please send such requests
to:
CHOICE Administrators
Attn: Legal Department 721
South Parker, Suite 200
Orange, CA 92868
Changes to Our Notice of Privacy Policy and Insurance Information Practices
We reserve the right to change our privacy policies and insurance information practices. If we make any changes to our policies or practices, we will provide you with a copy of a
revised notice as required by applicable law.
Our Commitment
CHOICE Administrators values you as a customer, and we are committed to bringing you products and services that help you to feel healthier and more secure. Our goal is to
always use your information in a responsible business manner. If there are state and federal law requirements that prohibit sharing your information without your written permission,
CHOICE Administrators will comply with those requirements.
14631
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Form 1: BUSINESS ASSOCIATE PRIVACY AGREEMENT A. Definitions (Dickerson Insurance Services)

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