Complete_with_Docusign_HIPAA.pdf
PDF 10 MB Posted
- Attached to
- Master Agreement AZ|CTR071447
- Contract number
- CTR071447
- Issued by
- Arizona
About this file
This document is a Business Associate Agreement (BAA) between the Arizona Department of Child Safety (ADCS) and Sacred Journey Inc., focusing on compliance with the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act, and related privacy regulations. The agreement establishes the terms under which Sacred Journey Inc. will handle Protected Health Information (PHI) in connection with services provided to ADCS.
The agreement defines the responsibilities of Sacred Journey Inc. as a Business Associate in safeguarding electronic Protected Health Information (ePHI), including restrictions on use and disclosure, implementation of appropriate security measures, reporting of any impermissible uses or breaches, and ensuring that any subcontractors adhere to the same privacy and security standards. The document outlines the permitted uses of PHI, which are limited to those necessary for performing services for ADCS, and establishes protocols for data aggregation, de-identification, and retention of records. The term of the agreement is tied to the underlying contract between the parties, with provisions for termination and protection of PHI in various scenarios.
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Text version
DocuSign Envelope ID: 3A6813B4-B860-42B5-BDD2-3D40E1C82011
30th
Marisa Lucero
May 2024
Certificate Of Completion Envelope Id: 3A6813B4B86042B5BDD23D40E1C82011 Status: Completed
Subject: Complete with Docusign: HIPAA.pdf
Source Envelope:
Document Pages: 10 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
5/30/2024 9:38:39 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: 5/30/2024 9:43:17 AM
Viewed: 5/30/2024 9:43:24 AM
Signed: 5/30/2024 9:43:42 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 5/30/2024 9:43:17 AM
Certified Delivered Security Checked 5/30/2024 9:43:24 AM
Signing Complete Security Checked 5/30/2024 9:43:42 AM
Completed Security Checked 5/30/2024 9:43:42 AM
Payment Events Status Timestamps
| 2024-05-30T09:44:23-0700 | |
| Digitally verifiable PDF exported from www.docusign.com |
File details come from the government source that posted it. Updated .