CONTRACT RE 3RD PARTY REIMBURSE WITH TAPI.PDF

January 1, 2019 December 31, 2023

SECTION I GENERAL PROVISIONS
1. EFFECT
To the extent the Special Provisions are in conflict with the General Provisions, the Special
Provisions shall control. To the extent the Work Statement(s) and the Special or General
Provisions are in conflict, the Work Statement(s) shall control.
2. DEFINITIONS
As used throughout this Contract, the following terms shall have the following meanings:
A. Contract means this document and all exhibits, attachments, appendices, and
amendments to this Contract.
B. Contractor means the person, firm, or organization listed on the Cover Page of
this Contract.
C. County means Maricopa County, Arizona.
D. Department means the Maricopa County Department of Public Health (MCDPH).
E. Director means the Director of the Department.
F. Funding Source means any Federal, State, or Private Agency funding source that
may impose conditions on the funding that will be passed on to the Contractor.
3. GENERAL REQUIREMENTS
A. The terms of this Contract shall be construed in accordance with Arizona law. Any
lawsuit arising out of this Contract shall be brought in the appropriate court in
Maricopa County, Arizona.
B. The Contractor shall, without limitation, obtain and maintain all licenses, permits,
and authority necessary to do business, render services, and perform work under
this Contract, and shall comply with all laws regarding Unemployment Insurance,
Disability Insurance, and Workers’ Compensation.
C. The Contractor is an independent Contractor in the performance of work and the
provision of services under this Contract and is not to be considered an officer,
employee, or agent of the County.
4. AMENDMENTS
All Amendments to this Contract shall be in writing and signed by the Parties.
5. ADEQUACY OF RECORDS
If the Contractor's books, records, and other documents relevant to this Contract are not
sufficient to support and document that allowable services were provided to eligible
persons, the Contractor shall reimburse the County for the services not sufficiently
supported and documented.
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SECTION I GENERAL PROVISIONS
6. RETENTION OF RECORDS
A. This provision applies to all financial and programmatic records, supporting
documents, statistical records, and other records of the Contractor, which are
reasonably considered as relevant to this Contract.
B. The Contractor shall retain all financial books, records, and other documents
relevant to this Contract for five (5) years after final payment or until after the
resolution of any audit questions, which could take more than five (5) years,
whichever is longer. The County, Federal, or State auditors, and any other
persons duly authorized by the County, shall have full access to, and the right to
examine, copy, and make use of any and all such materials.
7. ASSIGNMENT / SUBCONTRACTING
No rights, liability, obligations, or duties under this Contract may be assigned, delegated,
or subcontracted without the prior written approval of the County.
8. AUDIT DISALLOWANCES
A. The Contractor shall, upon written demand therefore, reimburse the County for any
payments made under this Contract that are disallowed by a Federal, State, or
Maricopa County audit in the amount of the disallowance, as well as all expenses,
court costs, and attorney fees the County incurs in connection with any legal action
relating to such disallowance.
B. If, at any time, the County determines that a cost for which payment has been
made is a disallowed cost, the County shall notify the Contractor in writing of the
disallowance and the required course of action, which may be, at the option of the
County, either to adjust any future claim submitted by the Contractor by the amount
of the disallowance or to require repayment of the disallowed amount by the
Contractor.
9. CONTRACT COMPLIANCE MONITORING
The County shall monitor the Contractor's compliance with, and performance under, the
terms and conditions of this Contract. Announced or unannounced on-site visits for
Contract compliance monitoring may be made by the County and its grantor agencies at
any time during the Contractor's normal business hours. During the visit, the Contractor
shall make available for inspection and copying by the County, all records and accounts
relating to the work performed or the services provided under this Contract, or for similar
work and service provided under other grants and contracts.
10. AVAILABILITY OF FUNDS
A. The provisions of this Contract relating to payment for services shall become
effective when funds assigned for the purpose of compensating the Contractor, as
herein provided, are actually available to the County for disbursement. The County
shall be the sole judge and authority in determining the availability of funds under
this Contract and the County shall keep the Contractor fully informed as to the
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SECTION I GENERAL PROVISIONS
availability of funds.
B. If any action is taken by any State Agency, Federal Department, or any other
agency or instrumentality to suspend, decrease, or terminate its fiscal obligations
under or in connection with this Contract, the County may amend, suspend,
decrease, or terminate its obligations under or in connection with this Contract. In
the event of termination, the County shall be liable for payment only for services
rendered prior to the effective date of the termination, provided such services are
performed in accordance with the provisions of this Contract. The County shall
give at least ten (10) days prior written notice of the effective date of any
suspension, amendment, or termination under this section.
11. CONTINGENCY RELATING TO OTHER CONTRACTS AND GRANTS
A. The Contractor shall, during the term of this Contract, immediately inform the
County in writing of the award of any other contract or grant where the award of
such contract or grant may affect either the direct or indirect costs being paid or
reimbursed under this Contract. Failure by the Contractor to notify the County of
such award shall be considered a material breach of this Contract and the County
shall have the right to terminate this Contract without liability.
B. The County may request, and the Contractor shall provide within a reasonable
time, a copy of any other contract or grant when, in the opinion of the Director, the
award of the other contract or grant may affect the costs being paid or reimbursed
under this Contract.
C. If the County determines that the award to the Contractor of such other Federal or
State contract or grant has affected the costs being paid or reimbursed under this
Contract, the County shall prepare a Contract Amendment effecting a cost
adjustment. If the Contractor protests the proposed cost adjustment, the protest
shall be considered a dispute within the meaning of the "Disputes" clause
contained herein.
12. NON-APPROPRIATION OF FUNDS
Notwithstanding any other provision herein, this Contract may be terminated without
liability if the Maricopa County Board of Supervisors does not appropriate sufficient monies
for the purpose of maintaining this Contract.
13. DEFAULT
The County may suspend, modify, or terminate this Contract immediately upon written
notice to the Contractor in the event of a non-performance of stated objectives or other
material breach of contractual obligations; or upon the happening of any event that may
jeopardize the ability of the Contractor to perform any of its contractual obligations.
14. TERMINATION FOR CONVENIENCE
A. The County or the Contractor may terminate this Contract at any time with at least
thirty (30) days prior written notice to the other Party.
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SECTION I GENERAL PROVISIONS
B. This Contract may be terminated by mutual written agreement of the Parties
specifying the termination date therein.
15. TERMINATION FOR BREACH
The County may terminate this Contract upon twenty-four (24) hours’ notice when the
County deems the health or welfare of any person is endangered or the Contractor’s
noncompliance jeopardizes funding source financial participation.
If either Party defaults under this Contract and the default continues for more than ten (10)
days after the effective date of the other Party’s written notice stating the specific nature
of the default, then the noticing Party may treat the default as a breach of this Contract.
Upon a breach, the aggrieved Party may exercise any remedy available under the law,
including the termination of this Contract.
16. SEVERABILITY
Any provision of this Contract that is determined by a court of competent jurisdiction to be
invalid, void, or illegal shall not affect, impair, or invalidate any other provision hereof, and
the remaining provisions shall remain in full force and effect.
17. STRICT COMPLIANCE
Acceptance by the County of performance not in strict compliance with the terms of this
Contract shall not be construed as a waiver of the requirement of strict compliance for all
future performance obligations. All changes in performance obligations under this
Contract shall be in writing.
18. NON-LIABILITY
The County and its officers and employees shall not be liable for any act or omission by
the Contractor or any subcontractor, employee, officer, agent, or representative of the
Contractor or subcontractors that occurs during the performance of this Contract, nor shall
they be liable for any purchases, debts, or agreements made by the Contractor in
anticipation of funding hereunder.
19. INDEMNIFICATION:
To the fullest extent permitted by law, and to the extent that claims, damages, losses or
expenses are not covered and paid by insurance purchased by the Contractor, the
Contractor shall defend indemnify and hold harmless the County (as Owner), its agents,
representatives, agents, officers, directors, officials, and employees from and against all
claims, damages, losses, and expenses (including, but not limited to attorneys' fees, court
costs, expert witness fees, and the costs and attorneys' fees for appellate proceedings)
arising out of, or alleged to have resulted from the negligent acts, errors, omissions, or
mistakes relating to the performance of this Contract.
Contractor's duty to defend, indemnify, and hold harmless the County, its agents,
representatives, agents, officers, directors, officials, and employees shall arise in
connection with any claim, damage, loss, or expense that is attributable to bodily injury,
sickness, disease, death or injury to, impairment of, or destruction of tangible property,
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SECTION I GENERAL PROVISIONS
including loss of use resulting there from, caused by negligent acts, errors, omissions, or
mistakes in the performance of this Contract, but only to the extent caused by the negligent
acts or omissions of the Contractor, a subcontractor, any one directly or indirectly
employed by them, or anyone for whose acts they may be liable, regardless of whether or
not such claim, damage, loss, or expense is caused in part by a party indemnified
hereunder.
The amount and type of insurance coverage requirements set forth herein will in no way
be construed as limiting the scope of the indemnity in this paragraph.
The scope of this indemnification does not extend to the sole negligence of County.
20. COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or selling agency has been employed or retained
to solicit or secure this Contract upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee. For breach or violation of this warranty, the
County may terminate this Contract without liability.
21. SAFEGUARDING CLIENT INFORMATION
The use or disclosure by any Party of any information concerning an eligible person served
under this Contract is directly limited to the performance of this Contract.
22. RIGHTS IN DATA
The Parties shall have the use of data and reports resulting from this Contract without cost
or other restriction, except as may otherwise be provided herein or by law or applicable
regulation. Each Party shall supply to the other Party, upon request, any available
information known to the supplying Party that is relevant to this Contract and to the
performance hereunder.
23. NON-DISCRIMINATION
Contractor agrees to comply with all provisions and requirements of Arizona Executive
Order 2009-09 including flow down of all provisions and requirements to any
subcontractors. Executive Order 2009-09 supersedes Executive order 99-4 and amends
Executive order 75-5 and may be viewed and downloaded at the Arizona State Library
Research website
(http://azmemory.azlibrary.gov/cdm/singleitem/collection/execorders/id/680/rec/1) which
is hereby incorporated into this contract as if set forth in full herein. During the performance
of this Contract, Contractor shall not discriminate against any employee, client or any other
individual in any way because of that person’s age, race, creed, color, religion, sex,
disability or national origin.
24. EQUAL EMPLOYMENT OPPORTUNITY
The Contractor shall not discriminate against any employee or applicant for employment
because of race, creed, age, disability, color, religion, sex, or national origin. The
Contractor shall take affirmative action to ensure that applicants are employed and that
employees are treated during employment without regard to their race, creed, age,
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SECTION I GENERAL PROVISIONS
disability, color, religion, sex, or national origin. Such action shall include, but is not limited
to, the following: employment, upgrading, demotion or transfer, recruitment or recruitment
advertising, lay-off or termination, rates of pay or other forms of compensation, and
selection for training, including apprenticeship. The Contractor shall, to the extent such
provisions apply, comply with Titles VI and VII of the Federal Civil Rights Act; the Federal
Rehabilitation Act; the Age Discrimination in Employment Act; the Immigration Reform and
Control Act of 1986 (IRCA); and Arizona Executive Order 2009-09, which mandates that
all persons shall have equal access to employment opportunities. The Contractor shall
also comply with all applicable provisions of the Americans with Disabilities Act of 1990.
25. RIGHT OF PARTIAL CANCELLATION
If more than one activity is funded by this Contract, the County reserves the right to
terminate this Contract or any part thereof based on the Contractor's failure to perform any
part of this Contract without impairing, invalidating, or canceling the remaining Work
Statement obligations.
26. RIGHT TO EXTEND CONTRACT
Subject to the availability of funds and acceptable Contractor performance, the Contractor
hereby acknowledges and agrees that the County shall have the right to extend this
Contract for additional one-year periods, not to exceed a total extended term of five (5)
years, except that the cost will be subject to renegotiation. Any extension of this Contract
shall be in a writing mutually acceptable to the Department and the Contractor and signed
by both Parties.
27. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
A. The undersigned (authorized official signing on behalf of the Contractor) certifies
to the best of his or her knowledge and belief, that the Contractor, it’s current
officers and directors;
1) are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any Federal
Department or agency; voluntarily excluded from being awarded any
contract or grant by any United States Department or Agency or any state,
or local jurisdiction;
2) have not within three (3) year period preceding this Contract;
a. been convicted of fraud or any criminal offense in connection with
obtaining, attempting to obtain, or as the result of performing a
government entity (Federal, State or local) transaction or contract; and
b. been convicted of violation of any Federal or State antitrust statues or
conviction for embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen
property regarding a government entity transaction or contract;
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SECTION I GENERAL PROVISIONS
c. are not presently indicted or criminally charged by a government entity
(Federal, State or local) with commission of any criminal offenses in
connection with obtaining, attempting to obtain, or as the result of
performing a government entity public (Federal, State or local)
transaction or contract; and are not presently facing any civil charges
from any governmental entity regarding obtaining, attempting to obtain,
or from performing any governmental entity contract or other
transaction; and have not within a three (3) year period preceding this
Contract had any public transaction (Federal, State or local) terminated
for cause or default.
3) If any of the above circumstances described in the paragraph are
applicable to the entity submitting a bid for this requirement, include with
your bid an explanation of the matter including any final resolution.
B. The Contractor shall include, without modification, this clause in all lower tier
covered transactions (i.e. transactions with subcontractors) and in all solicitations
for lower tier covered transactions related to this Contract.
28. VERIFICATION REGARDING COMPLIANCE WITH A.R.S. §41-4401 AND FEDERAL
IMMIGRATION LAWS AND REGULATIONS:
A. By entering into the Contract, the Contractor warrants compliance with the
Immigration and Nationality Act (INA using e-verify) and all other Federal
immigration laws and regulations related to the immigration status of its employees
and A.R.S. §23-214(A). The Contractor shall obtain statements from its
subcontractors certifying compliance and shall furnish the statements to the
Procurement Officer upon request. These warranties shall remain in effect through
the term of the Contract. The Contractor and its subcontractors shall also maintain
Employment Eligibility Verification forms (I-9) as required by the Immigration Reform
and Control Act of 1986, as amended from time to time, for all employees performing
work under the Contract and verify employee compliance using the E-verify system
and shall keep a record of the verification for the duration of the employee’s
employment or at least three years, whichever is longer. I-9 forms are available for
download at USCIS.GOV.
B. The County retains the legal right to inspect Contractor and subcontractor employee
documents performing work under this Contract to verify compliance with paragraph
1.32.1 of this Section. Contractor and subcontractor shall be given reasonable notice
of the County’s intent to inspect and shall make the documents available at the time
and date specified. Should the County suspect or find that the Contractor or any of
its subcontractors are not in compliance, the County will consider this a material
breach of the Contract and may pursue any and all remedies allowed by law,
including, but not limited to: suspension of work, termination of the Contract for
default, and suspension and/or debarment of the Contractor. All costs necessary to
verify compliance are the responsibility of the Contractor.
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SECTION II SPECIAL PROVISIONS
1. MEDIATION/ARBITRATION
In the event that any dispute arises out of this Contract or involves a recipient of services
under the terms of this Contract, the Parties shall meet and confer in an effort to resolve
the dispute. In the event that such efforts to resolve the dispute are unsuccessful, the
Parties shall resolve the dispute by arbitration pursuant to A.R.S. § 12-1518(A).
2. CHANGES
A. The Director may, at any time, by written order, make changes within the scope of
this Contract in any one or more of the following areas:
1). Work Statement activities reflecting changes in the scope of services,
Funding Source, or County regulations, policies, or requirements.
2). Administrative requirements, such as changes in reporting periods,
frequency of reports, or report formats required by funding source, or
County regulations, policies, or requirements.
3). Contractor reimbursement schedules and program budgets
B. The Director shall not increase or decrease the maximum reimbursable amount to
be paid the Contractor without an official amendment to this Contract. Additionally,
the Director shall not direct substantive changes in services to be rendered by the
Contractor.
C. Any dispute or disagreement caused by such written order shall constitute a
"Dispute" within the meaning of the Disputes Clause of the Special Provisions of
this Contract and shall be administered accordingly.
3. SPECIAL REQUIREMENTS
A. If the use of subcontractors is approved by County, the Contractor shall use written
subcontracts or consultant agreements that conform to Federal and State laws and
regulations, and to the requirements of this Contract appropriate to the service or
activity covered by the subcontract. These provisions apply with equal force to the
subcontract as if the subcontractor were the Contractor referenced herein. The
Contractor is responsible for performing under this Contract whether or not
Subcontractors are used. The Contractor shall submit a copy of each Subcontract
to the County within fifteen (15) days of its effective date.
B. The Contractor shall include in any subcontracts a provision to the effect that the
subcontractor agrees that the County shall have access to the subcontractor’s
facilities and the right to examine any books, documents, and records of the
subcontractor involving transactions related to the subcontract and that such
books, documents, and records shall not be disposed of except as provided herein.
4. INSURANCE
A. The Contractor shall have in effect at all times during the term of this Contract
insurance or comparable self-insurance that is adequate to protect the County, its
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SECTION II SPECIAL PROVISIONS
officers, employees, property, and equipment against the losses set forth below.
The Contractor shall provide the County with a certificate of insurance or a certified
copy of the insurance policy naming the County as an additional insured, or, if the
Contractor is self-insured, shall provide the County with a letter indicating that it is
self-insured.
B. The following types and amounts of insurance are required as minimums:
1.) Workers’ Compensation and Unemployment Insurance as required by law.
2.) Unemployment Insurance as required by Arizona Law.
3.) Public liability, bodily injury, and property damage policies that insure
against claims for liability for the Contractor’s negligence or maintenance
of unsafe vehicles, facilities, or equipment brought by clients receiving
services pursuant to this Agreement and by lawful visitors of such clients.
The limits of the policies shall not be less than $1,000,000 per occurrence
and $2,000,000 aggregate.
C. Automobile and Truck Liability, Bodily Injury and Property Damages:
1.) General Liability, each occurrence; $1,000,000.00
2.) Property Damage; $1,000,000.00
3.) Combined single limit; $1,000,000.00
D. Standard minimum deductible amounts are allowable. Any losses applied against
insurance deductible are the sole responsibility of the Contractor.
E. Professional Liability:
1.) Insurance for the Contractor and its Agents, Employees, and other
Contractor Staff shall be maintained with coverage limits of one million
dollars ($1,000,000) per person, three million dollars ($3,000,000) per
occurrence.
2.) The Contractor agrees that in the event it, or any of its Agents, Employees,
or other Contractor Staff working under this Contract, is named as a
defendant in litigation, or is identified in a written notice of claim wherein
professional misconduct is alleged, the Contractor shall promptly notify the
Director in writing. The duty to notify under this paragraph applies whether
or not the County is claimed to be involved, is named as a party to the
matter, or could be potentially liable as a party.
F. The Contractor shall immediately inform the Director in writing of any cancellation
or its insurance or any decrease in its lines of coverage at least thirty (30) days
before such action takes place.
5. STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST
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SECTION II SPECIAL PROVISIONS
Notice is given that pursuant to A.R.S. § 38-511, the County may cancel this Contract
without penalty or further obligation within three years after execution of this Contract, if
any person significantly involved in initiating, negotiating, securing, drafting, or creating
this Contract on behalf of the County is at any time while this Contract or any extension of
this Contract is in effect, an employee or agent of any other Party to this Contract in any
capacity or consultant to any other Party of this Contract with respect to the subject matter
of this Contract. Additionally, pursuant to A.R.S. § 38-511, the County may recoup any
fee or commission paid or due to any person significantly involved in initiating, negotiating,
securing, drafting, or creating this Contract on behalf of the County from any other Party
to this Contract arising as the result of this Contract.
This Contract may be cancelled pursuant to A.R.S. § 38-511.
6. LAWS, RULES AND REGULATIONS
The Contractor and the County understand and agree that this Contract is subject to all
applicable State and Federal laws, rules, and regulations.
A. Neither this Contract, nor any portion thereof, may be assigned to another person
by the Department without the written consent of the Contractor’s designated
representative. Any attempt by the Department to assign any portion of this
Contract without the written consent of the Contractor shall constitute a breach of
this Contract.
B. No assignment shall alter the Department’s responsibility to the Contractor to
assure that all of the provisions under this Contract are carried out by its assignee.
All terms and conditions in this Contract shall be included in the Department’s
assignments.
7. REPORTING REQUIREMENTS
If requested by the County, the Contractor shall submit monthly, quarterly, and annual
progress reports on or before the third (3rd) day of the month following the end of the
reporting period. In addition, a quarterly expenditure report will be submitted with the
quarterly progress report.
8. POLICY ON CONFIDENTIALITY
The Contractor and the County understand and agree that this Contract is subject to all
State and federal laws protecting client confidentiality of medical, behavioral health and
drug treatment information.
9. COMMUNICATION
The Contractor shall assume primary responsibility for effective, efficient communication
with MCDPH staff.
10. SPONSORSHIP ACKNOWLEDGMENT
All promotional materials, brochures, and flyers prepared by the Contractor shall include
the following statement, “Sponsored by Maricopa County Department of Public Health”
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SECTION II SPECIAL PROVISIONS
11. ISRAEL BOYCOTT
By submitting this Contract the Contractor certifies that they are in compliance with Article
9, A.R.S. Section 35-393 et seq.
12. UNIFORM ADMINISTRATIVE REQUIREMENTS
By entering into this Contract the Contractor agrees to comply with all applicable
provisions of Title 2, Subtitle A, Chapter II, PART 200—UNIFORM ADMINISTRATIVE
REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL
AWARDS contained in Title 2 C.F.R. § 200 et seq.
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SECTION III WORK STATEMENT
A. Scope of Work
This agreement will establish a program operated by TAPI to coordinate billing
for public health clinics so that counties and Maricopa County Department of
Public Health can be compensated for services to health plan members. TAPI will
ensure that the health plans have claims data records for their clients. Maricopa
County Department of Public Health will receive payment for appropriately billed
services (administration fee and/or vaccines) for services provided to privately
insured clients as well as clients listed to be on the Arizona State Medicaid Program
Arizona health Care Cost Containment System (AHCCCS).
B. Contractor Will:
1. Coordinate contracts for public health services billing with each commercial
health plan.
2. Coordinate process for reimbursement for commercial health plan patients.
3. Communicate with Arizona Department of Health Services (ADHS), Vaccine
for Children (VFC), and Arizona State Immunization Information System
(ASIIS) to ensure necessary financial collaboration.
4. TAPI agrees to use safe guards to ensure data is Health Insurance
Portability and Accountability Act (HIPAA) compliant and patient data
protected.
5. TAPI will make available support equipment recommendations based
on industry standards.
6. TAPI will offer education services on claims processed for Maricopa County
Department of Public Health Immunization Clinics when requested.
7. TAPI will offer general immunization education and updates to Maricopa
County Department of Public Health staff as needed and requested.
8. For the billing process TAPI will:
i. Process Claims on behalf of Maricopa County Department of Public
Health
ii. Communicate information for each individual health plan
iii. Receive payment for submitted claims
iv. Reimburse Maricopa County Department of Public Health for a portion
of the claims payments received
C. Maricopa County Department of Public Health Will:
1. Use a standard billing encounter form which conforms to regulatory billing
requirements.
2. Train staff to verify insurance at the clinics using online real time insurance
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SECTION III WORK STATEMENT
eligibility tool provided by TAPI. This will assist the Clinics to provide private
vs. VFC vaccine at the point of service.
3. Provide TAPI the cost per dose of all vaccines to be billed, to ensure accuracy
for the payment calculation.
.
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1. COMPENSATION
A. BILLING
TAPI will receive 40% of the claims paid for administrative fees; as well as 40%
of claims paid for vaccine reimbursement above Maricopa County Department
of Public Health's cost of vaccines. Over time the payment methodology will be
revised, once sufficient volumes of private vaccine billing are available to enable
an accurate vaccine revenue and expense projection to ensure that both TAPI
and Maricopa County Department of Public Health's costs are covered. All
changes in percentage will be done through an amendment to this contract in
writing and signed by both parties.
B. EDUCATION / OUTREACH
TAPI will submit invoices no more than 20 days after the scheduled
education/outreach took place. Each invoice must include (or documentation
attached) a log of the type of education/outreach provided, how many individuals
obtained the education/outreach, and an itemized list of expenditures being billed
for.
2. METHOD OF PAYMENT
A. TAPI will pay MCDPH on the 15th day of each month.
3. NOTICE
Any notice given under this Agreement shall be sent to the attention of the following:
Program: Contractor:
Maricopa County Department of Public Health The Arizona Partnership for Immunization
Office of Community Wellness and Health
Promotion
Attn: Machrina Leach Attn: Patty Gast
4041 N. Central Ave, Ste 600 700 E. Jefferson Street, Ste 100
Phoenix, AZ 85012 Phoenix, AZ 85034
Phone: (602) 506-6662 Phone: (602) 288-7572
Department:
Maricopa County Department of Public Health
Office Acquisitions and Grants Management
Attn: Grants Administrator
4041 N Central Ave, Suite 1400
Phoenix, AZ 85012
Phone: (602) 372-0675
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MARICOPA COUNTY
By and Through its
Department of Public Health (MCDPH),
BUSINESS ASSOCIATE AGREEMENT
This Agreement sets out the responsibilities and obligations of The Arizona Partnership for Immunization (“Business
Associate” or “Associate”) as a business associate of the MARICOPA COUNTY, a covered entity, under the Health
Insurance Portability and Accountability Act (“HIPAA”), the Health Information Technology for Economic and Clinical
Health (“HITECH”) Act, and pursuant to the Contract or Engagement Letter between Associate and MARICOPA
COUNTY.
MARICOPA COUNTY may make available and/or transfer to Associate Protected Health Information (“PHI”) of
individuals in conjunction with Services, which Associate will use or disclose only in accordance with this Agreement.
Associate and MARICOPA COUNTY agree to the terms and conditions of this Agreement in order to comply with the
use and handling of PHI under the HIPAA Standards for Privacy of Individually Identifiable Health Information, 45
C.F.R. Part 160 and Part 164, Subpart E (“Privacy Standards”) and the HIPAA Security Standards, 45 C.F.R. Part
160 and Part 164, Subpart C (“Security Standards”), both as amended from time to time. Unless otherwise provided,
all capitalized terms in this Agreement will have the same meaning as provided under the Privacy Standards and
Security Standards. Associate and MARICOPA COUNTY will comply with the terms of this Agreement for the
duration of the Contract or Engagement Letter and for such other continuing periods as provided in this Agreement.
Upon the compliance date of any final regulation or amendment to final regulation promulgated by the Secretary of
Health and Human Services that affects Associate’s use or disclosure of PHI, the parties agree to take such
reasonable action as is necessary to amend this Agreement in order for MARICOPA COUNTY to comply with such
final regulation or amendment to final regulation.
Definitions for terms in this Agreement:
1. Business Associate or Associate means an entity that performs or assists in the performance of a function on
behalf of a Covered Entity, which involves the use, or disclosure of Individually Identifiable Health Information
as defined in 45 C.F.R. § 160.103. In addition, an Associate can be an entity that provides data transmission
services to a Covered Entity, is more than a mere conduit of information, and allows a Covered Entity to
access the maintained information in a manner beyond a random or infrequent basis. The terms “Business
Associate”, “Associate” and “Contractor” are synonymous. Notwithstanding this definition, if Contractor does
not have access to or create Protected Health Information under this Contract, Contractor is not an
Associate, and the terms of this Agreement do not apply to Contractor.
2. Contractors of Business Associate means a person or an entity to whom an Associate delegates a function,
activity, or service that the Associate has agreed to perform for a Covered Entity. A contractor of an
Associate which creates, receives, maintains, or transmits personal health information on behalf of the
business associate is itself a Business Associate and therefore will comply with the terms of this Agreement.
For purposes of this Agreement the term “Contractor” includes the Contractor, its employees, its
subcontractors and its agents.
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3. Protected Health Information (“PHI”) means the health information that is created or received by a Covered
Entity; and relates to the physical condition, mental health or other health condition of an Individual, or to the
provision of health care to the Individual (including but not limited to the payment for such health care); and
identifies or can be used to identify the Individual as defined in 45 C.F.R. § 160.103.
4. Individual shall have the meaning set forth in 45 CFR §160.103, including a person who is the subject of the
Protected Health Information, and shall include an individual or entity who qualifies as a personal, legal
representative of the person, as the context requires.
5. Privacy Rule shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR
Parts 160 and 164, Subparts A and E, as may be amended, modified or superseded, from time to time.
6. Security Rule shall mean the Standards for Security of Individually Identifiable Electronic Health Information at
45 CFR Parts 160 and 164, Subparts A, C and E, as may be amended, modified or superseded, from time to
time.
7. Breach shall mean the acquisition, access, use or disclosure of Protected Health Information in a manner not
permitted by the HIPAA Privacy Rule, that compromises the security or privacy of the Protected Health
Information as defined, and subject to the exception given to such term in 45 C.F.R. § 164.402.
8. Breach Notification Rule shall mean the interim final rule related to breach notification for unsecured protected
health information at 45 C.F.R. Parts 160 and 164.
9. Covered Entity shall have the meaning given to such term in 45 C.F.R. § 160.103.
10. Designated Record Set shall have the meaning given to such term under the Privacy Rule at 45 C.F.R. §
164.501.
11. Security Incident shall have the meaning given to such phrase under the Security Rule at 45 C.F.R. § 164.304.
12. Unsecured PHI shall have the meaning given to such phrase under the Breach Notification Rule at 45 C.F.R. §
164.402.
13. Electronic Protected Health Information or ePHI shall have the same meaning given to such term under the
Security Rule, including, but not limited to, 45 C.F.R. § 160.103.
14. Electronic Media shall have the same meaning given to such term in 45 C.F.R. § 160.103.
15. Health Information Technology for Economic and Clinical Health (HITECH) Act, as codified at 42 U.S.C.
§§ 17921-17954.
16. Secretary shall mean the Secretary of the Department of Health and Human Services or his or her designee.
It is agreed by and between the parties that:
1. Uses and Disclosures of Protected Health Information. Associate will use and disclose PHI only for those
purposes necessary to perform its duties, obligations and functions under the Contract, or as otherwise
expressly permitted in this Agreement or as required by other law.
a. Associate will not use or further disclose any PHI in violation of this Agreement.
b. Associate may use PHI to perform data aggregation services as permitted by 45 C.F. R. § 164.504(e) (2)
(i) (B).
c. Associate agrees that anytime it provides PHI received from MARICOPA COUNTY to a Contractor, its
employees, subcontractor, or agent to perform Services for MARICOPA COUNTY, Associate first will
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enter into a contract with such Contractor, employees, subcontractor or agent that contains the same
terms, conditions, and restrictions on the use and disclosure of PHI as contained in this Agreement.
d. If Associate maintains a Designated Record Set, MARICOPA COUNTY will provide Associate with copies
of applicable policies and procedures, which the Associate will comply with as related to an individual’s
right to access PHI; request an amendment to PHI; request confidential communications of PHI; or
request an accounting of disclosures of PHI.
2. Associate Use or Disclosure of Protected Health Information for its Own Purposes. Associate may use or
disclose PHI received from MARICOPA COUNTY for Associate’s management and administration, or to carry
out Associate’s legal and contractual responsibilities. Associate may disclose PHI received from MARICOPA
COUNTY to a third party for such purposes only if:
a. The disclosure is required by law; or
b. Associate secures written assurance from the receiving party that the receiving party will: (i) hold the PHI
confidentially; (ii) use or disclose the PHI only as required by law or for the purposes for which it was
disclosed to the recipient; and (iii) notify the Associate of any breaches in the confidentiality of the PHI.
c. Associate may use and disclose de-identified health information, if (i) the use is disclosed to MARICOPA
COUNTY and permitted by MARICOPA COUNTY in its sole discretion, (ii) that the de-identification is in
compliance with 45 C.F.R. § 164.502(d), and (iii) the de-identified health information meets the standard
and implementation specifications for de-identification under 45 C.F.R. § 164.514(a) and (b).
d. Associate shall use and disclose PHI only to the extent reasonably necessary to accomplish the intended
purpose of such PHI.
3. Safeguards. Associate will implement and maintain appropriate safeguards to prevent any use or disclosure of
PHI not otherwise permitted in this Agreement.
a. Associate also will implement administrative, physical and technical safeguards to protect the
confidentiality, integrity, and availability of any electronic protected health information (“e-PHI”), if any,
that Associate creates, receives, maintains, and transmits on behalf of MARICOPA COUNTY.
b. Upon request of MARICOPA COUNTY, Associate will provide evidence to MARICOPA COUNTY that
these safeguards are in place and are properly managed.
4. Reports of Improper Use or Disclosure of Secure or Unsecure Protected Health Information and of
Security Incidents and Breaches. Associate will report in writing to MARICOPA COUNTY any use or
disclosure of PHI, including any breach, not permitted by the contract between Associate and MARICOPA
COUNTY within five (5) days of Associate’s learning of such use, disclosure or breach or within five (5) days
following the exercise of reasonable diligence would have known of the improper use, disclosure, or breach.
5. Mitigation of potential harmful effects. Associate shall mitigate all potential harmful effects of a use or
disclosure of Protected Health Information by Business Associate in violation of the requirements of this
Agreement. Immediately following the Associate’s discovery of a Breach (or upon the Associate’s reasonable
belief that a Breach has occurred), Associate shall provide MARICOPA COUNTY with sufficient information to
permit MARICOPA COUNTY to comply with the Breach notification requirements set forth at 45 C.F.R.
§164.400 et seq.
a. Specifically, if the following information is known to (or can be reasonably obtained by) the Associate,
Associate will provide to MARICOPA COUNTY all available information that MARICOPA COUNTY is
required to include in its notification to the individual pursuant to the Breach Notification Rule, including
but not limited to:
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i. contact information for individuals who were or who may have been impacted by the Breach (e.g.,
first and last name, mailing address, street address, phone number, email address);
ii. a brief description of the circumstances of the Breach, including the date of the Breach, the date of
discovery of the Breach, and the identity of who accessed and received the Unsecured PHI;
iii. a description of the types of unsecured PHI involved in the Breach (e.g., names, social security
number, date of birth, address(s), account numbers of any type, disability codes, diagnostic and/or
billing codes and similar information);
iv. a brief description of what the Associate has done or is doing to investigate the Breach, mitigate
harm to the individual impacted by the Breach, and protect against future Breaches; and
v. contact information for a liaison appointed by the Associate with whom MARICOPA COUNTY may
ask questions and learn additional information concerning the Breach.
b. Following a Breach, Associate will have a continuing duty to inform MARICOPA COUNTY of new
information learned by Associate regarding the Breach, including but not limited to the information
described in items (1) through (5), above.
c. Associate also will report in writing to MARICOPA COUNTY any Security Incident (successful or
unsuccessful) of which Associate becomes aware within five (5) business days of Associate learning of
such use or disclosure.
Specifically, Associate will report to MARICOPA COUNTY any unauthorized access, use, disclosure,
modification, or destruction of e-PHI or interference with system operations in an information system
containing e-PHI of which Associate becomes aware, provided that:
i. such reports will be provided only as frequently as the parties mutually agree, but no more than once
per month; and
ii. if the definition of “Security Incident” under the Security Standards is amended to remove the
requirement for reporting “unsuccessful” attempts to use, disclose, modify or destroy e-PHI, the
portion of this Section 5 addressing the reporting of unsuccessful, unauthorized attempts will no
longer apply as of the effective date of such amendment.
6. Obligations Regarding Associate Personnel. Associate will appropriately inform all of its employees, agents,
representatives, members of its workforce, and Contractors, its employees, subcontractors, or agents of
Associate (“Associate Personnel”), whose services may be used to satisfy Associate’s obligations under the
Contract and this Agreement of the terms of this Agreement. Associate represents and warrants that the
Associate Personnel are under legal obligation to Associate, by contract or otherwise, sufficient to enable
Associate to fully comply with the provisions of this Agreement. Associate will maintain a system of sanction for
any Associate Personnel who violates this Agreement.
7. Access to Protected Health Information.
a. MARICOPA COUNTY Access. Within five (5) business days of a request by MARICOPA COUNTY for
access to PHI received from MARICOPA COUNTY, Associate will make requested PHI available to
MARICOPA COUNTY.
b. Patient Access. If a Patient requests access to PHI directly from Associate, Associate will within five (5)
business days forward such request in writing to MARICOPA COUNTY. MARICOPA COUNTY will be
responsible for making all determinations regarding the grant or denial of a Patient’s request for PHI and
Associate will make no such determinations. Only MARICOPA COUNTY will release PHI to the Patient
pursuant to such a request.
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8. Amendment of Protected Health Information.
a. MARICOPA COUNTY Request. Within five (5) business days of receiving a request from MARICOPA
COUNTY to amend an individual’s PHI received from MARICOPA COUNTY, Associate will provide such
information to MARICOPA COUNTY for amendment. Alternatively, if MARICOPA COUNTY request
includes specific information to be included in the PHI as an amendment, Associate will incorporate such
amendment within five (5) business days of receipt of the MARICOPA COUNTY request.
b. Individual Request. If an individual makes a request for amendment directly to Associate, Associate will
forward within five business days such request in writing to MARICOPA COUNTY. MARICOPA COUNTY
will be responsible for making all determinations regarding amendments to PHI and Associate will make
no such determinations.
9. Accounting of Disclosures; Requests for Disclosure.
a. Disclosure Records. Associate will keep a record of any disclosure of PHI received from MARICOPA
COUNTY that Associate makes to its employees, subcontractors, and agents, or other third parties other
than:
(1) Disclosures to health care providers to assist in the treatment of patients;
(2) Disclosures to others to assist MARICOPA COUNTY in paying claims;
(3) Disclosures to others to assist MARICOPA COUNTY in conducting its health care operations, as
defined in 45 C.F.R. § 164.501; or
(4) Disclosures made pursuant to an individual’s Authorization.
Associate will maintain this disclosure record for six (6) years from the termination of this Agreement.
Associate also agrees to maintain necessary and sufficient documentation of Disclosures of Protected Health
Information as would be required for MARICOPA COUNTY to respond to a request by an individual for an
accounting of Disclosures, in accordance with 45 CFR 164.528.
b. Data Regarding Disclosures. For each disclosure for which it is required to keep a record under
paragraph 8(a), Associate will record and maintain the following information:
(1) The date of disclosure;
(2) The name of the entity or person who received the PHI, and, the address of such entity or person, if
known.
(3) A description of the PHI disclosed; and
(4) A brief statement of the purpose of the disclosure.
c. Provision to MARICOPA COUNTY. Associate will provide to MARICOPA COUNTY its record of
disclosures under paragraph 8(a), if any, within thirty days of each disclosure. Within five business days
of receiving a notice from MARICOPA COUNTY of an individual’s request for an accounting, Associate
also will provide to MARICOPA COUNTY its disclosure record.
d. Patient Request to Associate. If a Patient requests and accounting of disclosures directly from
Associate, Associate will forward the request to MARICOPA COUNTY within five (5) business days of
Associate’s receipt of the request, and will make its records of disclosures available to MARICOPA
COUNTY as otherwise provided in this Section. MARICOPA COUNTY will be responsible to prepare and
for delivery of the records of disclosure to the Patient. Associate will not provide an accounting of its
disclosure directly to the Individual.
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10. Notice of Privacy Practices. MARICOPA COUNTY shall provide Associate a copy of its Notice of Privacy
Practices (“Notice”) in accordance with 45 C.F.R. § 164.520 as well as any changes to the Notice. If
MARICOPA COUNTY’ Notice specifically affects Associate’s use or disclosure of PHI, MARICOPA COUNTY
shall inform Associate of the specific limitations. Associate shall abide by the limitations of MARICOPA
COUNTY’ Notice that affects its use or disclosure of PHI of which it has been specifically informed. Any use or
disclosure permitted by this Agreement may be amended by changes to MARICOPA COUNTY’ Notice if
MARICOPA COUNTY specifically informs Associate of the amendment: provided, however, that the amended
Notice shall not affect permitted uses and disclosures on which Associate relied prior to receiving notice of such
amended Notice.
11. Access to Books and Records.
a. MARICOPA COUNTY Access. Associate will, within five (5) business days of MARICOPA COUNTY
written request, make available during normal business hours at Associate’s offices, all records, books,
agreements, policies and procedures relating to the use or disclosure of PHI received from MARICOPA
COUNTY for the purpose of allowing MARICOPA COUNTY or its agents or auditors to determine
Associate’s compliance with this Agreement.
b. Government Access. Associate will make its internal practices, books, and records relating to the use
and disclosure of PHI received from, or created or received by Associate on behalf of, MARICOPA
COUNTY available to the Secretary of the Department of Health and Human Services to the extent
required for determining compliance with the Privacy Standards. Notwithstanding this provision, no
attorney-client, accountant-client or other legal privilege will be deemed waived by Associate or
MARICOPA COUNTY as a result of this Section.
12. Termination. MARICOPA COUNTY may immediately terminate the Contract, if any and this Agreement upon
written notice to Associate if MARICOPA COUNTY determines that the Associate or subcontractor(s) or
agent(s) of Associate has breached a material term of this Agreement. Alternatively, MARICOPA COUNTY may
elect to provide Associate with written notice of Associate’s or subcontractor(s)’ or agent(s)’ of Associate breach
of any term or condition of this Agreement and afford Associate the opportunity to cure the breach to the
satisfaction of MARICOPA COUNTY within thirty (30) days of the date of such notice. If Associate fails to timely
cure the breach, as determined by MARICOPA COUNTY at its sole discretion, MARICOPA COUNTY may
terminate the Contract and this Agreement.
13. Return or Destruction of Protect Health Information.
a. Return of PHI; Destruction. Within thirty (30) days of termination of the Contract or this Agreement,
Associate will return to MARICOPA COUNTY all PHI received from MARICOPA COUNTY or created or
received by Associate on behalf of MARICOPA COUNTY that Associate maintains in any form or format.
Associate will not maintain or keep in any form or format any portion of such PHI. Alternatively, Associate
may, upon MARICOPA COUNTY written consent, destroy all such PHI and provide written documentation
of such destruction. The requirement to return or destroy such PHI will apply to all agents or
subcontractors of Associate. Associate will be responsible for recovering any PHI from such agents or
subcontractors. If Associate cannot obtain the PHI from any agent or subcontractor, Associate will so
notify MARICOPA COUNTY and will require that such agents or subcontractors directly return PHI to
MARICOPA COUNTY or otherwise destroy such PHI, subject to the terms of this Section.
b. Alternative Measures. Upon termination of this Agreement for any reason, Associate, with respect to
protected health information received from MARICOPA COUNTY, or created, maintained, or received by
Associate on behalf of MARICOPA COUNTY, shall:
1. Retain only that protected health information which is necessary for Associate to continue its proper
management and administration or to carry out its legal responsibilities;
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2. Return to MARICOPA COUNTY the remaining protected health information that the Associate still
maintains in any form;
3. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect
to electronic protected health information to prevent use or disclosure of the protected health
information, other than as provided for in this Section, for as long as Associate retains the protected
health information;
4. Not use or disclose the protected health information retained by Associate other than for the
purposes for which such protected health information was retained and subject to the same
conditions set out above in section 1, “Uses and Disclosures of Protected Health Information,” and
section 2, “Associate Use or Disclosure of Protected Health Information for its Own Purposes,” which
applied prior to termination; and
5. Return to MARICOPA COUNTY the protected health information retained by Associate when it is no
longer needed by Associate for its proper management and administration or to carry out its legal
responsibilities.
14. Restrictions on Use or Disclosure of Protected Health Information. If MARICOPA COUNTY advises
Associate of any changes in, or restrictions to, the permitted use or disclosure of PHI received from MARICOPA
COUNTY, Associate will restrict the use or disclosure of such PHI consistent with the MARICOPA COUNTY
instructions.
15. Mitigation Procedures. Associate agrees to have procedures in place for mitigating, to the maximum extent
practicable, any deleterious effect from the use or disclosure of PHI received from MARICOPA COUNTY in a
manner contrary to this Agreement or the Privacy Standards.
16. Compliance with the HITECH Act. Associate will comply with the requirements of Title XII, Subtitle D of the
Health Information Technology for Economic and Clinical Health (HITECH) Act, codified at 42 U.S.C. §§ 17921-
17954, which are applicable to Associates, and will comply with all regulations issued by the Department of
Health and Human Services (HHS) to implement these referenced statutes, as of the date by which Associates
are required to comply with such referenced statutes and HHS regulations.
a. Associate will also comply with Section 13402 of the HITECH Act, codified at 42 U.S.C. § 17932, and
with all regulations issued by HHS to implement this statute, as of the date by which Associates are
required to comply with such referenced statutes and HHS regulations. Associate will make a report to
the MARICOPA COUNTY of any breach of unsecured protected health information, as required by 42
U.S.C. § 17932(b), within five (5) business days of Associate’s discovery of the breach. Associate will
indemnify MARICOPA COUNTY for any reasonable expenses MARICOPA COUNTY incurs in notifying
individuals of a breach caused by Associate or its subcontractors or agents.
17. Miscellaneous.
a. Compliance with Laws. The Parties acknowledge that state and federal laws relating to electronic data
security and privacy are rapidly evolving and that amendment of this Agreement may be required to
ensure compliance with such developments. Should such developments occur, and upon either Party’s
good faith request, the other Party agrees to enter good faith negotiations concerning the terms of an
amendment to this Agreement.
b. Construction of Terms. The terms of this Agreement will be construed in light of any applicable
interpretation or guidance on the Privacy Standards and Security Standards issued by the Department of
Health and Human Services and other applicable state or federal laws, rules and regulations as amended
from time to time.
c. No Third Party Beneficiaries. Nothing in this Agreement will confer upon any person other than the
parties and their respective successors or assigns, any rights, remedies, obligations, or liabilities,
whatsoever.
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d. Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to the
benefit of the Parties hereto and their respective successors and permitted assigns. However, neither
Party may assign any of its rights or delegate any of its obligations under this Agreement without prior
written consent of the other Party, which consent shall not be unreasonable withheld or delayed.
Notwithstanding any provisions to the contrary, however, MARICOPA COUNTY retains the right to assign
or delegate any of its rights and obligations hereunder to any of its wholly owned subsidiaries, affiliates or
successor companies. Assignments made in violation of this provision are null and void.
e. No Waiver. Failure or delay on the part of either Party to exercise any right, power, privilege or remedy
hereunder shall not constitute a waiver thereof. No provision of this Agreement may be waiver by either
Party except by a writing signed by an authorized representative of the Party making the waiver.
f. Severability. The provisions of this Agreement shall be severable, and if any provision of this Agreement
shall be held or declared to be illegal, invalid or unenforceable, the remainder of this Agreement shall
continue in full force and effect as though such illegal, invalid or unenforceable provision had not been
contained herein.
g. Entire Agreement. This Agreement constitutes the entire agreement between the parties with regard to
the Privacy Standards and Security Standards, there are no understandings or agreements relating to this
Agreement that are not fully expressed in this Agreement and no change, waiver or discharge of
obligations arising under this Agreement will be valid unless in writing and executed by the party against
whom such change, waiver or discharge is sought to be enforced.
h. Written Agreement. This Agreement is considered as an integral part of the underlying Contract, and is
incorporated as though fully set forth within the Contract. This Agreement will govern in the event of
conflict or inconsistency with any provision of Contract.
i. Choice of Law. This Agreement and the rights and obligations of the parties hereunder shall be
governed by and construed under the laws of the State of Arizona, without regard to applicable conflict of
law principles.
j. Counterparts. This Agreement may be executed in two or more counterparts, each of which shall be
deemed an original and when taken together shall constitute one agreement.
k. Facsimile and Electronic Signatures. Facsimile and electronic signatures shall be deemed to be
original signatures for all purposes of this Agreement.
l. Notices. Any notices required under this Agreement will be sent to the parties at the following address
by first class mail, fax or hand delivery:
MARICOPA COUNTY THE ARIZONA PARTNERSHIP FOR
IMMUNIZATION
BOARD OF SUPERVISORS
301 W. Jefferson Street, 10th Floor 700 E. Jefferson Street, Ste 1000
Phoenix, AZ 85003 Phoenix, AZ 85034
(602) 506-3416 (602) 372-0675
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Agreed to by MARICOPA COUNTY and Associate by:
MARICOPA COUNTY THE ARIZONA PARTNERSHIP FOR IMMUNIZATION
_____________________________________ _________________________________
SIGNATURE DATE SIGNATURE DATE
Steve Chucri, Chairman, Board of Supervisors Patty Gast, M.S, Program Manager
PRINT NAME AND TITLE PRINT NAME AND TITLE
ATTEST:
_____________________________________
Clerk of the Board Date
APPROVE AS TO FORM:
_____________________________________
Attorney for Maricopa County Date
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BUSINESS ASSOCIATE AGREEMENT
FOR RELEASE OF INFORMATION TO THIRD PARTIES
1. _______________________________ (“Associate”) is a business associate of MARICOPA COUNTY,
pursuant to the Agreement between Associate and MARICOPA COUNTY dated __________
(“Agreement”). Pursuant to that Agreement, Associate is required to comply with the requirements for the
use and handling of Protected Health Information (“PHI”) from MARICOPA COUNTY as set forth in the
Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. 164.501 et. seq. as amended
from time to time (“Privacy Standards”).
2. Associate is permitted to disclose PHI to _______________ (“Recipient”) for the necessary management
and administration of Associate and to carry out the legal responsibilities of the Associate, provided that
Recipient provides Associate with the following assurances for Recipient’s use and disclosure of PHI.
3. Associate seeks to disclose PHI to Recipient for the following management, administration or legal
responsibilities of Associate:
4. The disclosure of PHI to Recipient is conditioned upon Recipient’s assurance that, and Recipient agrees
that it will:
a. Hold the PHI confidentially and make no re-disclosure to any third party without Associate’s express
advance written consent;
b. Use or disclose the PHI only as required by law or for the purposes set forth above; and
c. Notify Associate in writing of any breaches in the confidentiality of the PHI within three days of
discovery of any such breach.
ASSOCIATE RECIPIENT
_____________________________________ _______________________________
SIGNATURE DATE SIGNATURE DATE
_____________________________________ ________________________________
PRINT NAME AND TITLE. PRINT NAME AND TITLE
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