ADCS_Business_Agreement_HITECH-signed.pdf
PDF 5 MB Posted
- Attached to
- Master Agreement AZ|CTR071440
- Contract number
- CTR071440
- Issued by
- Arizona
About this file
This document is a Business Associate Agreement (BAA) between the Arizona Department of Child Safety (ADCS) and Mi Casa Su Casa, LLC, executed under the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. The agreement is designed to ensure compliance with federal and state privacy and security standards for protected health information (PHI).
The BAA outlines the responsibilities of Mi Casa Su Casa, LLC as a business associate in handling, protecting, and managing electronic protected health information (ePHI) on behalf of ADCS. The agreement specifies strict protocols for data use, disclosure, security, and breach notification, including requirements to use only the minimum necessary PHI, implement appropriate safeguards, report any impermissible use or disclosure within one business day, and maintain records for six years. The contract includes provisions for termination in cases of material breach, with options for cure, and emphasizes that the business associate has no ownership rights to the protected information.
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Text version
DocuSign Envelope ID: 44AA36C4-5B24-4337-9DF7-BD25852D2DE6
10th
May 2024
Marisa Lucero
Certificate Of Completion Envelope Id: 44AA36C45B2443379DF7BD25852D2DE6 Status: Completed
Subject: Complete with DocuSign: ADCS Business Associate Agreement HITECH.pdf
Source Envelope:
Document Pages: 9 Signatures: 1 Envelope Originator:
Certificate Pages: 1 Initials: 0 Marisa Lucero
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-07:00) Arizona
3003 N. Central Ave
14th Floor
Phoenix, AZ 85012
Marisa.Lucero@AZDCS.GOV
IP Address: 159.87.110.136
Record Tracking Status: Original
5/10/2024 8:03:18 AM
Holder: Marisa Lucero
Marisa.Lucero@AZDCS.GOV
Location: DocuSign
Security Appliance Status: Connected Pool: StateLocal
Storage Appliance Status: Connected Pool: AZDCS - Guardian (114816690) Location: DocuSign
Signer Events Signature Timestamp Marisa Lucero marisa.lucero@azdcs.gov
Security Level: Email, Account Authentication (None)
Signature Adoption: Pre-selected Style
Using IP Address: 159.87.110.136
Sent: 5/10/2024 8:03:58 AM
Viewed: 5/10/2024 8:04:06 AM
Signed: 5/10/2024 8:04:30 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 5/10/2024 8:03:58 AM
Certified Delivered Security Checked 5/10/2024 8:04:06 AM
Signing Complete Security Checked 5/10/2024 8:04:30 AM
Completed Security Checked 5/10/2024 8:04:30 AM
Payment Events Status Timestamps
| 2024-05-10T08:06:07-0700 | |
| Digitally verifiable PDF exported from www.docusign.com |
File details come from the government source that posted it. Updated .