1. PWS (Ambulances ISO UC25) -- 4 JUN 25 v2 (002).pdf

STATEMENT OF WORK (SOW)

USTRANSCOM’s Exercise Ultimate Caduceus 2025 (UC25) Ambulance Transportation

David Grant Medical Center Travis AFB, California

4 June 2025

UC25 Ambulance Services

1. Description of Services: In accordance with Air Mobility Command (AMC) Commander's Intent, AMC Forces and staff will execute Patient Movement (PM) operations 28 Jul - 1 Aug 2025 at Travis AFB. Also, Travis AFB will activate as an Aeromedical Evacuation (AE) Hub to receive three aircraft for in/out-bound patient movement missions for 60 patients daily. David Grant USAF Medical Center will activate as Federal Coordination Center (FCC) Sacramento, with direction and control to regulate patients off-base to the surrounding 8-counties and 23-hospitals within a 65 mile radius from Travis AFB from 28 Jul - 1 Aug 2025 to support the execution of National Disaster Medical System (NDMS) operations.

The following are FCC Sacramento affiliated NDMS partners:

-Dameron Hospital, Stockton, CA (San Joaquin County) -Kaiser Medical Center, Vacaville, CA (Solano County) -Kaiser Medical Center, Vallejo, CA (Solano County) -Kaiser Medical Center, Manteca, CA (San Joaquin County) -Mercy General Hospital, Sacramento, CA (Sacramento County) -Lodi Memorial Hospital, Lodi, CA (San Joaquin County) -North Bay Health Medical Center, Fairfield, CA (Solano County) -North Bay VacaValley Hospital, Vacaville, CA (Solano County) -Sutter Solano Medical Center, Vallejo, CA (Solano County) -Sonoma Valley Hospital, Sonoma, CA (Sonoma County) -Woodland Memorial, Woodland, CA (Yolo County) -Sutter Medical Center, Sacramento, CA (Sacramento County) -St. Helena Hospital, Deer Park, CA (Napa County) -Methodist Hospital, Sacramento, CA (Sacramento County) -Petaluma Valley Hospital, Petaluma, CA (Sonoma County) -Mercy San Juan Hospital, Carmichael, CA (Sacramento County) -Sutter Medical Center, Roseville, CA (Placer County County) -Mercy Hospital, Folsom, CA (Sacramento County) -Santa Rosa Memorial Hospital, Santa Rosa, CA (Santa Rosa County) -Sutter Hospital, Davis, CA (Yolo County) -Queen of the Valley Medical Center, Napa, CA (Napa County) -UC Davis Medical Center, Sacramento, CA (Sacramento County) -VA Medical Center, Sacramento, CA (Sacramento County)

Not all FCC Sacramento affiliated NDMS partners will participate in this exercise.

2. Requirements:

2.1. The ambulance company shall provide the requirements listed below in the chart. The ambulance company will ensure the ambulances and crews will arrive on-scene at Travis AFB, Hangar 810, no later than 9:30 am with duty until 3:30 pm (6-hours) daily.

Each day, the ambulance company will ensure the company’s staff and vehicles will process thorough the Travis Air Force Base Visitors Center (with a Real-ID) with sufficient time to not negatively impact this exercise.

Ambulances will transport Exercise Patients from the Travis AFB Patient Reception Site (PRS), Hangar 810, to volunteer participating civilian hospitals which may span the surrounding 8-counties and 21 hospitals (listed above). The ambulance company may be required to retrieve exercise patients from participating hospitals to be returned to Travis AFB for onward movement to another state.

Mileage will begin at the PRS and will vary day-by-day based on the volunteer participation of FCC Sacramento NDMS partners. The ambulance company’s grand total mileage will not exceed 2,400.

At the end of each duty day, the Ambulance Strike Team Leader will provide the FCC Sacramento Coordinator a daily reconciliation of miles driven and the associated cost for that day and a running total including the previous days mileage. The ambulance company will bill all mileage at the conclusion of this exercise.

Dates Detailed Description Quantity (unit) Total Unit Hours Duty Hours

7/28/2025 BLS Standby Unit 2 6 0930-1530

7/28/2025 Ambulance and Driver Only 1 6 0930-1530

7/29/2025 BLS Standby Unit 4 6 0930-1530

7/29/2025 Ambulance and Driver Only 2 6 0930-1530

7/30/2025 BLS Standby Unit 4 6 0930-1530

7/30/2025 Ambulance and Driver Only 2 6 0930-1530

7/31/2025 BLS Standby Unit 4 6 0930-1530

7/31/2025 Ambulance and Driver Only 2 6 0930-1530

8/1/2025 BLS Standby Unit 2 6 0930-1530

8/1/2025 Ambulance and Driver Only 1 6 0930-1530

7/28/2025 Strike Team Leader 1 6 0930-1530

7/29/2025 Strike Team Leader 1 6 0930-1530

7/30/2025 Strike Team Leader 1 6 0930-1530

7/31/2025 Strike Team Leader 1 6 0930-1530

8/1/2025 Strike Team Leader 1 6 0930-1530

2.2. The PRS Commander and Ambulance Strike Team Leader will be the primary Command and Control node. The PRS Commander will communicate mission details and requests for support to the Ambulance Strike Team Leader. The Strike Team Leader must have a method of communication to provide additional guidance/direction to ambulances in the field.

2.3. Contractor personnel shall be certified, licensed, or otherwise officially recognized by the local, state of regional government or public entity where the emergency ambulance service is operated or by which it is governed.

Service Deliverable Summary

1254651555C Highlight

3. Manage Services: The Contractor shall ensure that all requirements issued under this contract are followed to include standards identified in the SOW. The Contractor shall maintain customer satisfaction rates and required level of performance. The Contractor shall ensure they met all performance requirements and are prepared to begin performance at the location, time and date stated in this SOW.

4. Resolving Service Performance Issues: The Contractor shall resolve issues within the timeframe specified by the Government. The Contractor shall have a process for resolving issues and concerns, implementing corrective actions, and communicating the resolution to DGMC Contract Management office by the suspense date issued by the Government. The Contractor shall conduct follow-up to ensure corrective actions are successful.

5. General Information:

5.1. Security Requirements: All personnel employed by the contractor in the performance of this contract, or any representative of the contractor entering the governmental installation, shall abide by all security regulations of the installation.

5.1.1. Security: All contractor employees shall comply with the security and background check requirements required by Federal, State, Local and the Department of Defense to gain access to base to provide this service, to include presenting a “Real-ID” or military identification to process through the Travis Air Force Base visitors center. Travis AFB is designated as a closed base. All contractors needing access must adhere to installation entry requirements, to include, criminal background history (CBH) checks, National Crime Information Center (NCIC) wants/warrants checks and California Law Enforcement Telecommunication System (CLETS) driver license history checks. A CBH check is not required for contractors if they have a current favorable government security clearance which can be verified through the Defense Information System for Security (DISS).

5.1.2. Criminal Background Checks: Contractors whose criminal background meets any of the following 12 disqualifiers will not be allowed installation access.

• U.S. citizenship, immigration status, or social security account number cannot be verified.

• Barred from entry/access to any military installation or facility.

• Wanted by federal or civil law enforcement authorities, regardless of offense or violation.

• Name appears on any federal agency’s list for criminal behavior or terrorist activity.

• Convicted of espionage, sabotage, treason or terrorism.

• Incarcerated for 12 months or longer within the past three years, regardless of offense or violation.

• Convicted of a firearms or explosives violation within the past three years.

• Convicted of illegal possession or use of drugs/narcotics on more than one occasion within five years from the date access to Travis AFB is requested.

• Convicted of an offense involving drug trafficking, possession with intent to sell or drug distribution within 10 years from the date access to Travis AFB is requested.

• Convicted of a felony involving violence against a person, arson, robbery or burglary within five years from the date access to Travis AFB is requested.

• Required to register as a sex offender under federal law or the applicable state law.

• Convicted of any crime involving indecent acts with a minor or a felony that is sexual in nature.

5.2. Primary Contractor Responsibilities: The primary contractor will be responsible for the conduct of all contractors working under that contract. Additionally, the primary contractor will:

5.2.1. Coordinate base entry requirements and pass with the DGMC Contract Management office.

5.2.1.1. To obtain a pass: The contractor’s full name, date of birth and social security number will be provided to the DGMC Contract Management office for a Base Pass Request.

Additionally, personnel will need a valid state or government photo identification.

5.2.1.2. To obtain a vehicle pass: The Contractor will need a valid driver’s license, registration, and insurance.

5.2.2. Advise contractors that the badge/pass is only valid for the purpose, person and vehicle for which it was issued. Use of the badge/pass for any other purpose or by any other person will result in the pass being confiscated. Contractor vehicle may not be parked overnight on the military installation. Contractors that misuse their pass may face revocation of installation access privileges and/or barment actions.

5.2.3. Provide written notification, within one week, to the DGMC Contract Management office of any changes in contractor status. This includes, but is not limited to, the contractor being fired or quitting their position with the company.

5.2.4. Retrieve government issued personal and vehicle passes from contractors which no longer need installation access upon termination of the contract. Passes will be turned into the Pass and Registration Office, Bldg. 599.

5.3. Lost Badges/Passes: The primary contractor will investigate and provide written notification for a lost badge/pass to the DGMC Contract Management office. Written notification should include an explanation from the contractor on how, when, where and what steps have been taken to locate the missing badge/pass.

5.4. Escort Requirements: Contractors when working in a Controlled, Restricted or other sensitive areas must be escorted at all times. The military agency or unit responsible for the project or work is responsible for providing the escorts. The contractor shall follow existing procedures and instructions for obtaining entrance to Controlled, Restricted and sensitive areas.

5.5. Increased Force Protection Condition (FPOCON): During FPCON Normal, Alpha and Bravo; contractors without a base issued badge/pass must be sponsored onto the installation.

During FPCON Charlie and Delta the base will curtail non-essential operations/functions and non-essential contractors will be suspended at the direction of the Installation Commander. All contractors attempting installation access; thereafter, will be physically escorted unless FPCON Mission-Essential designation has been approved in advance and is indicated on the badge/pass.

5.6. Initial Inspection: All contractor owned equipment will be inspected and approved by the Biomedical Equipment Maintenance Section prior to use in the Medical Treatment Facility.

Contact QAP to schedule inspection.

5.7. Removal of Equipment: Should the equipment or any component listed herein require repair at the contractor’s plant, contractor shall be responsible to obtain/transport equipment.

Contractor shall provide a loaner/replacement on-site until original is fully repaired. Contractor shall be responsible for damage or loss of equipment while in contractor’s possession.

6. Miscellaneous

6.1. Regulatory References: A reference in this Clause to a section in DoD 6025.18-R, DoD 8580.02-R, Privacy Rule or Security Rule means the section currently in effect or as amended, and for which compliance is required.

6.2. Survival: The respective rights and obligations of this contract under the “Effect of Termination” provision of this Clause shall survive the termination of this Contract.

6.3. Interpretation: Any ambiguity in this Clause shall be resolved in favor of a meaning that permits the Government to comply with DoD 6025.18-R, DoD 8580.02-R, the HIPAA Privacy Rule or the HIPAA Security Rule.

ATTACHMENT 1

HIPAA CLAUSE

In accordance with 45 CFR 164.502(e)(2) and 164.504(e) and paragraph C.3.4.1.3 of DoD 6025.18-R, “DoD Health Information Privacy Regulation,” January 24, 2003, this document serves as a business associate agreement (BAA) between the signatory parties for purposes of the Health Insurance Portability and Accountability Act (HIPAA) and the “HITECH Act” amendments thereof, as implemented by the HIPAA Rules and DoD HIPAA Issuances (both defined below). The parties are a DoD MHS component, acting as a HIPAA covered entity, and a DoD contractor, acting as a HIPAA business associate. The HIPAA Rules require BAAs between covered entities and business associates. Implementing this BAA requirement, the applicable DoD HIPAA Issuance (DoD 6025.18-R, paragraph C3.4.1.3) provides that requirements applicable to business associates must be incorporated (or incorporated by reference) into the contract or agreement between the parties.

(a) Catchall Definition. Except as provided otherwise in this BAA, the following terms used in this BAA shall have the same meaning as those terms in the DoD HIPAA Rules: Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices (NoPP), Protected Health Information (PHI), Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.

Breach means actual or possible loss of control, unauthorized disclosure of or unauthorized access to PHI or other PII (which may include, but is not limited to PHI), where persons other than authorized users gain access or potential access to such information for any purpose other than authorized purposes, where one or more individuals will be adversely affected. The foregoing definition is based on the definition of breach in DoD Privacy Act Issuances as defined herein.

Business Associate shall generally have the same meaning as the term “business associate” in the DoD HIPAA Issuances, and in reference to this BAA, shall mean Service Provider.

Agreement means this BAA together with the documents and/or other arrangements under which the Business Associate signatory performs services involving access to PHI on behalf of the MHS component signatory to this BAA.

Covered Entity shall generally have the same meaning as the term “covered entity” in the DoD HIPAA Issuances, and in reference to this BAA, shall mean David Grant Medical Center.

DHA Privacy Office means the DHA Privacy and Civil Liberties Office. The DHA Privacy Office Director is the HIPAA Privacy and Security Officer for DHA, including the National Capital Region Medical Directorate (NCRMD).

DoD HIPAA Issuances means the DoD issuances implementing the HIPAA Rules in the DoD MHS. These issuances are DoD 6025.18-R (2003), DoDI 6025.18 (2009), and DoD 8580.02-R (2007).

DoD Privacy Act Issuances means the DoD issuances implementing the Privacy Act, which are DoDD 5400.11 (2007) and DoD 5400.11-R (2007).

HHS Breach means a breach that satisfies the HIPAA Breach Rule definition of breach in 45

CFR 164.402.

HIPAA Rules means, collectively, the HIPAA Privacy, Security, Breach and Enforcement Rules, issued by the U.S. Department of Health and Human Services (HHS) and codified at 45 CFR Part 160 and Part 164, Subpart E (Privacy), Subpart C (Security), Subpart D (Breach) and Part 160, Subparts C-D (Enforcement), as amended by the 2013 modifications to those Rules, implementing the “HITECH Act” provisions of Pub. L. 111-5. See 78 FR 5566-5702 (Jan. 25, 2013) (with corrections at 78 FR 32464 (June 7, 2013)). Additional HIPAA rules regarding electronic transactions and code sets (45 CFR Part 162) are not addressed in this BAA and are not included in the term HIPAA Rules.

Service-Level Privacy Office means one or more offices within the military services (Army, Navy, or Air Force) with oversight authority over Privacy Act and/or HIPAA privacy compliance.

I. Obligations and Activities of Business Associate

(a) The Business Associate shall not use or disclose PHI other than as permitted or required by this Agreement or as required by law.

(b) The Business Associate shall use appropriate safeguards, and comply with the DoD HIPAA Rules with respect to electronic PHI, to prevent use or disclosure of PHI other than as provided for by this Agreement.

(c) The Business Associate shall report to Covered Entity any Breach of which it becomes aware, and shall proceed with breach response steps as required by Part V of this BAA. With respect to electronic PHI, the Business Associate shall also respond to any security incident of which it becomes aware in accordance with any Information Assurance provisions of this Agreement. If at any point the Business Associate becomes aware that a security incident involves a Breach, the Business Associate shall immediately initiate breach response as required by part V of this BAA.

(d) In accordance with 45 CFR 164.502(e)(1)(ii)) and 164.308(b)(2), respectively, and corresponding DoD HIPAA Issuances, as applicable, the Business Associate shall ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such PHI.

(e) The Business Associate shall make available PHI in a Designated Record Set, to the Covered Entity or, as directed by the Covered Entity, to an Individual, as necessary to satisfy the Covered Entity obligations under 45 CFR 164.524 and corresponding DoD HIPAA Issuances.

(f) The Business Associate shall make any amendment(s) to PHI in a Designated Record Set as directed or agreed to by the Covered Entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy Covered Entity’s obligations under 45 CFR 164.526, and corresponding DoD HIPAA Issuances.

(g) The Business Associate shall maintain and make available the information required to provide an accounting of disclosures to the Covered Entity or an individual as necessary to satisfy the Covered Entity’s obligations under 45 CFR 164.528 and corresponding DoD HIPAA Issuances.

(h) To the extent the Business Associate is to carry out one or more of Covered Entity's obligation(s) under the HIPAA Privacy Rule, the Business Associate shall comply with the requirements of the HIPAA Privacy Rule that apply to the Covered Entity in the performance of such obligation(s); and

(i) The Business Associate shall make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules.

II. Permitted Uses and Disclosures by Business Associate

(a) The Business Associate may only use or disclose PHI as necessary to perform the services set forth in this Agreement or as required by law. The Business Associate is not permitted to de-identify PHI under DoD HIPAA issuances or the corresponding 45 CFR 164.514(a)-(c), nor is it permitted to use or disclose de-identified PHI, except as provided by this Agreement or directed by the Covered Entity.

(b) The Business Associate agrees to use, disclose and request PHI only in accordance with the HIPAA Privacy Rule “minimum necessary” standard and corresponding DHA policies and procedures as stated in the DoD HIPAA Issuances.

(c) The Business Associate shall not use or disclose PHI in a manner that would violate the DoD HIPAA Issuances or HIPAA Privacy Rules if done by the Covered Entity, except uses and disclosures for the Business Associate’s own management and administration and legal responsibilities or for data aggregation services as set forth in the following three paragraphs.

(d) Except as otherwise limited in this Agreement, the Business Associate may use PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate. The foregoing authority to use PHI does not apply to disclosure of PHI, which is covered in the next paragraph.

(e) Except as otherwise limited in this Agreement, the Business Associate may disclose PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate, provided that disclosures are required by law, or the Business Associate obtains reasonable assurances from the person to whom the PHI is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

(f) Except as otherwise limited in this Agreement, the Business Associate may use PHI to provide Data Aggregation services relating to the Covered Entity’s health care operations.

III. Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions

(a) The Covered Entity shall notify the Business Associate of any limitation(s) in the notice of privacy practices of the Covered Entity under 45 CFR 164.520 and the corresponding provision of the DoD HIPAA Issuances, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI.

(b) The Covered Entity shall notify the Business Associate of any changes in, or revocation of, the permission by an Individual to use or disclose his or her PHI, to the extent that such changes affect the Business Associate’s use or disclosure of PHI.

(c) The Covered Entity shall notify the Business Associate of any restriction on the use or disclosure of PHI that the Covered Entity has agreed to or is required to abide by under 45 CFR

164.522 and the corresponding DoD HIPAA Issuances, to the extent that such changes may affect the Business Associate’s use or disclosure of PHI.

IV. Permissible Requests by Covered Entity

The Covered Entity shall not request the Business Associate to use or disclose PHI in any manner that would not be permissible under the HIPAA Privacy Rule or any applicable Government regulations (including without limitation, DoD HIPAA Issuances) if done by the Covered Entity, except for providing Data Aggregation services to the Covered Entity and for management and administrative activities of the Business Associate as otherwise permitted by this BAA.

V. Breach Response

(a) In general.

(1) In the event of a breach of PII/PHI held by the Business Associate, the Business Associate shall report the breach to the Covered Entity in accordance with Section VII, assess the breach incident, take mitigation actions as applicable, and notify affected individuals, as directed by the Covered Entity.

(2) The Business Associate shall coordinate all investigation actions with the Covered Entity, and at a minimum, follow the breach response requirements set forth in this Part V, which is designed to satisfy both the Privacy Act and HIPAA as applicable. If a breach involves PII without PHI, then the Business Associate shall comply with DoD Privacy Act Issuance breach response requirements only; if a breach involves PHI (a subset of PII), then the Business Associate shall comply with both Privacy Act and HIPAA breach response requirements. A breach involving PHI may or may not constitute an HHS Breach. If a breach is not an HHS Breach, then the Business Associate has no HIPAA breach response obligations. In such cases, the Business Associate must still comply with breach response requirements under the DoD Privacy Act Issuances.

(3) The Business Associate shall, at no cost to the Government, bear any costs associated with a breach of PII/PHI that the Business Associate has caused or is otherwise responsible for addressing.

(b) Government Reporting Provisions

(1) If the Covered Entity determines that a breach is an HHS Breach, then the Business Associate shall comply with both the HIPAA Breach Rule and DoD Privacy Act Issuances, as directed by the Covered Entity, regardless of where the breach occurs. If the Covered Entity determines that the breach does not constitute an HHS Breach, then the Business Associate shall comply with DoD Privacy Act Issuances, as directed by the applicable Service- Level Privacy Office.

(2) This Part V is designed to satisfy the DoD Privacy Act Issuances and the HIPAA Breach Rule as implemented by the DoD HIPAA Issuances. In general, for breach response, the Business Associate shall report the breach to the Covered Entity, assess the breach incident, notify affected individuals, and take mitigation actions as applicable. Because DoD defines “breach” to include possible (suspected) as well as actual (confirmed) breaches, the Business Associate shall implement these breach response requirements immediately upon the Business Associate’s discovery of a possible breach.

(3) The following provisions of Part V set forth the Business Associate’s Privacy Act and HIPAA breach response requirements for all breaches, including but not limited to HHS breaches.

(i) The Business Associate shall report the breach within one hour of discovery to the US Computer Emergency Readiness Team (US CERT), and, within 24 hours of discovery, to the Covered Entity, and to other parties as deemed appropriate by the Covered Entity. The Business Associate is deemed to have discovered a breach as of the time a breach (suspected or confirmed) is known, or by exercising reasonable diligence would have been known, to any person (other than the person committing it) who is an employee, officer or other agent of the Business Associate.

(ii) The Business Associate shall submit the US-CERT report using the online form at https://forms.us- cert.gov/report/. Before submission to US-CERT, the Business Associate shall save a copy of the on-line report. After submission, the Business Associate shall record the US- CERT Reporting Number. Although only limited information about the breach may be available as of the one hour deadline for submission, the Business Associate shall submit the US-CERT report by the deadline. The Business Associate shall e-mail updated information as it is obtained, following the instructions at http://www.us-cert.gov/pgp/email.html. The Business Associate shall provide a copy of the initial or updated US-CERT report to the Installation Privacy Act Officer, MTF HIPAA Privacy Officer, and the CO (if applicable), if requested. Business Associate questions about US- CERT reporting shall be directed to the Installation Privacy Act Officer or MTF HIPAA Privacy Officer, not the US-CERT office.

(iii) The Business Associate shall comply with the Breach Timeline and Notification Flow Chart processes attached to this Agreement, to include the timelines established for completing the DD Form 2959 and the HIPAA Privacy Incident Report.

(4) If multiple beneficiaries are affected by a single event or related set of events, then a single reportable breach may be deemed to have occurred, depending on the circumstances. The Business Associate shall inform the Covered Entity as soon as possible if it believes that “single event” breach response is appropriate; the Covered Entity will determine how the Business Associate shall proceed and, if appropriate, consolidate separately reported breaches for purposes of Business Associate report updates, beneficiary notification, and mitigation.

(i) When a Breach Report Form initially submitted is incomplete or incorrect due to unavailable information, or when significant developments require an update, the Business Associate shall submit a revised form or forms, stating the updated status and previous report date(s) and showing any revisions or additions in red text. Examples of updated information the Business Associate shall report include, but are not limited to: confirmation on the exact data elements involved, the root cause of the incident, and any mitigation actions to include, sanctions, training, incident containment, and follow-up. The Business Associate shall submit these report updates within three (3) business days after the new information becomes available. Prompt reporting of updates is required to allow the Covered Entity to make timely final determinations on any subsequent notifications or reports. The Business Associate shall provide updates to the same parties as required for the initial Breach Reporting Form. The Business Associate is responsible for reporting all information needed by the Covered Entity to make timely and accurate determinations on reports to HHS as required by the HHS Breach Rule and reports to the Defense Privacy and Civil Liberties Office as required by DoD Privacy Act Issuances.

(ii) In the event the Business Associate is uncertain on how to apply the above requirements, the Business Associate shall consult with the Covered Entity and CO (if applicable) when determinations on applying the above requirements are needed.

(c) Individual Notification Provisions

(i) If the Covered Entity determines that individual notification is required, the Business Associate shall provide written notification to individuals affected by the breach as soon as possible, but no later than 10 working days after the breach is discovered and the identities of the individuals are ascertained. The 10 day period begins when the Business Associate is able to determine the identities (including addresses) of the individuals whose records were impacted.

(ii) The Business Associate’s proposed notification to be issued to the affected individuals shall be submitted to the parties to which reports are submitted under paragraph VII for their review, and for approval by the CO, in consultation with the Covered Entity. Upon request, the Business Associate shall provide the CO and Covered Entity with the final text of the notification letter sent to the affected individuals. If different groups of affected individuals receive different notification letters, then the Business Associate shall provide the text of the letter for each group (PII shall not be included with the text of the letter(s) provided). Copies of further correspondence with affected individuals need not be provided unless requested by the Contracting Office or Covered Entity. The Business Associate’s notification to the individuals, at a minimum, shall include the following:

(A) The individual(s) must be advised of what specific data was involved. It is insufficient to simply state that PII has been lost. Where names, Social Security Numbers (SSNs) or truncated SSNs, and Dates of Birth (DOBs) are involved, it is critical to advise the individual that these data elements potentially have been breached.

(B) The individual(s) must be informed of the facts and circumstances surrounding the breach.

The description should be sufficiently detailed so that the individual clearly understands how the breach occurred.

(C) The individual(s) must be informed of what protective actions the Business Associate is taking or the individual can take to mitigate against potential future harm. The notice must refer the individual to the current Federal Trade Commission (FTC) web site pages on identity theft and the FTC’s Identity Theft Hotline, toll-free: 1-877-ID-THEFT (438-4338); TTY: 1-866-653- 4261.

(D) A brief description of what the covered entity involved is doing to investigate the breach, to mitigate harm to individuals, and to protect against any further breaches; and

(E) Contact procedures for individuals to ask questions or learn additional information, which shall include a toll- free telephone number, an e-mail address, Web site, or postal address

(F) The individual(s) must also be informed of any mitigation support services (e.g., one year of free credit monitoring, identification of fraud expense coverage for affected individuals, provision of credit freezes, etc.) that the Business Associate may offer affected individuals, the process to follow to obtain those services and the period of time the services will be made available, and contact information (including a phone number, either direct or toll-free, e-mail address and postal address) for obtaining more information. The CO, in consultation with the Covered Entity will determine the appropriate level of support services.

(iii) Business Associates shall ensure any envelope containing written notifications to affected individuals are clearly labeled to alert the recipient to the importance of its contents, e.g., “Important information – do not destroy,” and that the envelope is marked with the identity of the Business Associate and/or subcontractor organization that suffered the breach. The letter must also include contact information for a designated POC to include, phone number, e-mail address, and postal address.

(iv) If the Business Associate determines that it cannot readily identify, or will be unable to reach, some affected individuals within the 10 day period after discovering the breach, the Business Associate shall so indicate in the initial or updated Breach Report Form. Within the 10 day period, the Business Associate shall provide the approved notification to those individuals who can be reached. Other individuals must be notified within 10 days after their identities and addresses are ascertained. The Business Associate shall consult with the Covered Entity, which will determine which media notice is most likely to reach the population not otherwise identified or reached. The Business Associate shall issue a generalized media notice(s) to that population in accordance with the Covered Entity approval.

(d) Breaches are not to be confused with security incidents (often referred to as cyber security incidents when electronic information is involved), which may or may not involve a breach of

PII/PHI. In the event of a security incident not involving a PII/PHI breach, the Business Associate shall follow applicable DoD Information Assurance requirements under its Agreement. If at any point the Business Associate finds that a cyber-security incident involves a PII/PHI breach (suspected or confirmed), the Business Associate shall immediately initiate the breach response procedures set forth here. The Business Associate shall also continue to follow any requiredcyber security incident response procedures to the extent needed to address security issues, as determined by DoD/DHA.

VI. Termination

(a) Termination. Noncompliance by the Business Associate (or any of its staff, agents, or subcontractors) with any requirement in this BAA may subject the Business Associate to termination under any applicable default or other termination provision of the underlying Contract.

(b) Effect of Termination.

(1) If this Agreement has records management requirements, the Business Associate shall handle such records in accordance with the records management requirements. If this Agreement does not have records management requirements, the records should be handled in accordance with paragraphs VI.(2) and (3) below. If this Agreement has provisions for transfer of records and PII/PHI to a successor Business Associate, or if the Covered Entity gives directions for such transfer, the Business Associate shall handle such records and information in accordance with such Agreement provisions or the Covered Entity’s direction.

(2) If this Agreement does not have records management requirements, except as provided in the following paragraph (3), upon termination of this Agreement, for any reason, the Business Associate shall return or destroy all PHI received from the Covered Entity, or created or received by the Business Associate on behalf of the Covered Entity that the Business Associate still maintains in any form. This provision shall apply to PHI that is in the possession of subcontractors or agents of the Business Associate. The Business Associate shall retain no copies of the PHI.

(3) If this Agreement does not have records management provisions and the Business Associate determines that returning or destroying the PHI is infeasible, the Business Associate shall provide to the Covered Entity notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Covered Entity and the Business Associate that return or destruction of PHI is infeasible, the Business Associate shall extend the protections of this Agreement to such PHI and limit further uses and disclosures of such PHI to those purposes that make the return or destruction infeasible, for so long as the Business Associate maintains such

PHI.

VII. Execution

(a) Survival. The obligations of Business Associate under the “Effect of Termination” provision of this BAA shall survive the termination of the Agreement or any part thereof.

(b) Interpretation. Any ambiguity in the Agreement shall be resolved in favor of a meaning that permits the DoD Component and the Business Associate to comply with the HIPAA Rules and the DoD HIPAA Rules.