WvBaaAgEffectiveJun2013.pdf

This is an Appendix A form to a Business Associate Addendum for the Rural Health Transformation Program in West Virginia, designed to identify Protected Health Information (PHI) that will be handled under the agreement. The document serves as a pre-execution template for the Agency's Procurement Officer to enumerate and describe the categories of PHI that an associate will access or process in connection with the program's operations. The form identifies multiple categories of PHI including child information, dates of birth, disability information, emergency contacts, names, gender, health information, home addresses, maiden names, marital status, personal email addresses, phone numbers, race/ethnicity, and social security numbers. The appendix is intended to be completed prior to addendum execution and incorporated as part of the binding agreement, with provisions for amending the document via change order should additional PHI categories be identified after execution.

The document establishes a critical compliance mechanism for handling sensitive health information within the Rural Health Transformation Program's operations. Any PHI not identified prior to addendum execution requires formal amendment through change order procedures, ensuring clear documentation and authorization for all health information access and use. The form does not address pricing, funding sources, or specific contract terms, as it functions solely as a protective mechanism for identifying and controlling sensitive data in accordance with applicable health information privacy regulations.