WvBaaAgEffectiveJun2013.pdf

This file is an Appendix A template from the West Virginia Rural Health Transformation Program, designed to document protected health information (PHI) that may be accessed by associates working under a Business Associate Agreement (BAA) addendum. The template requires completion by the Agency's Procurement Officer prior to execution of the addendum and serves as an attachment to the addendum itself. The document establishes a framework for identifying and cataloging PHI before the agreement becomes effective, with provisions allowing amendments to Appendix A and the addendum via Change Order if additional PHI categories are identified after execution. The Rural Health Transformation Program has identified the following categories of PHI that may be accessed: Child Information, Date of Birth, Disability Information, Emergency Contact, First and Last Name, Gender, Health Information, Home Address, Maiden Name, Marital Status, Personal Email Address, Home and Mobile Phone, Race/Ethnicity, and Social Security Number.

The document does not contain specific pricing terms, set-asides, incumbent information, or funding details within the provided content. This template represents a protective measure to ensure compliance with health information privacy regulations and establishes clear documentation of what PHI associates will have access to under the business relationship, with a mechanism for tracking and updating such access through formal change orders rather than informal modifications.