Business Associates Web Form

Employees : Business Associates

Please complete the form below and send a copy of the underlying contract between the vendor and the University to our office, either via fax at 305-243-7487 or email hipaaprivacy@med.miami.edu. We will then determine if a business associate agreement is required and begin the process, if necessary.

All fields are required and you must click the Submit button at the bottom of this page. This form should only be completed by a member of the University’s workforce.

What is a business associate? To learn more, click here.

All fields with an * are required.

Contact Information

Department Name Division Department Contact Contact Title Phone Number E-mail Fax

Vendor/Business Associate Information

Vendor Name Contact Person Contact Title Contact email Address City State Zip Country Telephone Fax What services will be provided? Type of PHI Disclosure Purpose of Disclosure

Is this the only vendor who can provide this product or service?
Yes No

Is this vendor currently providing services to the University?
Yes No

If this vendor is not currently providing services, but has in the past, please provide the last date of service (MM/DD/YYYY)

Date

Questions or comments?

Office of Privacy & Data Security

Employees : Business Associates