MCAO SMI BA WEB PORTAL FILLABLE FORM - GOVT AGENCY FOR SIGNATURE.PDF

Business Associate Secure Web Portal
Government Agency
Registration Form
Thank you for your interest in registering for the Mercy Care Business Associate web portal. We
are committed to protecting the privacy of our members and Business Associates who use our
website. During registration, we ask you for specific information about you and your
Authorized Representatives. We will only use the information you submit to us for the purpose of
managing your access to the website. We do not disclose any of the information you provide to
us to any outside parties, except to manage the health plan or when applicable law may require it.
Registration Instructions: The information below and acceptance of the attached agreement
is required to complete registration.
Business Associate: Maricopa County through the Maricopa County Attorney's Office
Business Associate Tax ID # (TIN) (if applicable): 86-6000472
We caution against using your SSN in lieu of a TIN, as it presents unnecessary risks to your identity
Address: 225 West Madison St City: Phoenix State: AZ Zip: 85003
Phone #: 602-506-3411 Fax #: 602-506-2998
Business Associate must designate one primary representative (see Business Associate Web Portal
Agreement attached for full definition). Please indicate the full name and contact information of the
primary representative below:
Primary Representative Name: Vania Laguna, Legal Support Supervisor
Address: 225 West Madison St City: Phoenix State: AZ Zip: 85003
Phone #: 602-372-0092 Fax #:
E-Mail address at Business Associate’s office: lagunav@mcao.maricopa.gov
To submit a request for registration, please email your completed form, agreement and executed
Business Associate Agreement to Mercy Care at BAWebPortal@mercycareaz.org.
Business Associate Representative Signature Date
Chair, Maricopa County Board of Supervisors
Business Associate Representative Printed Name
Business Associate Web Portal Agreement
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Business Associate’s Web Portal Agreement
Introduction
This Business Associate’s Web Portal Agreement (“Agreement”) contains the terms and conditions that
govern the use of this web portal service by Business Associate to access information relating to Mercy
Care member/enrollee eligibility information.
Definitions
When used in this Agreement, all capitalized terms shall have the following meanings:
• “Administrator” means any Aetna administrator, such as Aetna Medicaid Administrators, LLC,
and any owners, affiliates or direct or indirect subsidiaries that administer or maintain the
Service for a Plan.
• “Authorized Representative” means an Employee of Business Associate that Business Associate
has authorized to use the Web Portal Service under this Agreement on Business Associate’s
behalf. Business Associate shall identify each authorized representative on the roster form
provided in Attachment A to this agreement. Addition or removal of an Authorized
Representative(s) shall be submitted, in writing, by the Primary Representative and shall
include the information requested in Attachment A.
• “Business Associate” means the individual or entity identified on the current Business Associate
Agreement (“BAA”) attached to this Agreement as Attachment B.
• “Government Sponsor” means a state agency or other governmental entity authorized to offer,
issue and/or administer one or more plans, and which, to the extent applicable, has contracted
with Plan to administer all or a portion of such Plan(s).
• “Member/enrollee” includes, a person determined to be Seriously Mentally Ill in accordance
with policies issued by the Arizona Health Care Cost Containment System (AHCCCS) and eligible
to receive behavioral health services paid for, in whole or in part, from funds available to the
AHCCCS designated Regional Behavioral Health Authority (RBHA)
• “Plan” means “Mercy Care” and any owners, affiliates or direct or indirect subsidiaries.
• “Primary Representative” means the Authorized Representative in the Business Associate’s
office who has responsibility for requesting access, removing access and maintaining the names
of Business Associate’s Authorized Representatives
• “Service” means the web portal service under this Agreement and the website that supports it.
Business Associate Web Portal Agreement
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Use of the Web Portal Service
The Service provides internet access to information on the Plan’s members’/enrollees’ eligibility and
enrollment. The Plan and its Administrator agree to permit Business Associate and its Primary
Representative and Authorized Representatives to use the Service, provided they comply with the
terms and conditions of this Agreement. Business Associate shall use the Service solely in connection
with its obligations under state and federal law, including court orders, for the provision of judicial
and/or health care services to Plan members/enrollees. Business Associate shall not access the
records or information of Plan members/enrollees to whom the Business Associate does not provide
judicial and/or health care services. The Primary Representative and each Authorized Representative
shall use the Service solely in the course and scope of employment or agency with Business Associate.
Business Associate shall use, and shall cause the Primary Representative and each Authorized
Representative to use, the Service subject to the following:
1. The terms and conditions of this Agreement; and
2. The applicable provisions of the BAA, including, but not limited to, use and disclosure of
Protected Health Information under the HIPPA Privacy Standards, and member/enrollee
eligibility and enrollment verification for the purposes identified in this Agreement.
3. In the event of a conflict between a term and condition under this Agreement and a provision
under the BAA, the terms of the BAA shall govern.
Business Associate shall require the Primary Representative and each Authorized Representative to:
1. Keep confidential and not disclose the Business Associate’s Service password to any person
except Business Associate or the Primary Representative;
2. Use the Service solely in connection with Business Associate’s judicial or health care services to
the Plan’s members/enrollees and within the course and scope of employment or agency with
Business Associate; and
3. Use the Service pursuant to the terms and conditions of this Agreement.
Upon learning that any Primary Representative or Authorized Representative has violated (1), (2) or
(3) identified above, changes job responsibilities such that access is no longer necessary, or no longer
works for or represents Business Associate, Business Associate shall immediately notify the Plan
within 24 hours. The Plan will revoke such Primary Representative’s or Authorized Representative’s
authority to use the Service.
Changes to the Web Portal Service or This Agreement
Administrator may, at any time, make changes to the Service, the terms and conditions in this
Agreement, or any other policies or conditions that govern the use of the Service at any time. Business
Associate should review the Service and these terms and conditions periodically for any updates or
changes. Business Associate’s continued access or use of the Service site shall be deemed Business
Associate’s notification and acceptance of these changes.
Business Associate Web Portal Agreement
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No Warranties or Liabilities
There is no implied warranty of any kind under this Agreement, including any representation of
accuracy, completeness, or appropriateness or fitness for a particular part of the Service, and non-
infringement. Business Associate assumes full responsibility for using the Service, and understands and
agrees that neither the Plan nor Administrator are responsible or liable for any claim, loss, or damage
resulting from, or related to, Business Associate’s use. Business Associate uses the Service at its own
risk, and agrees to use the Service on an “AS IS” and an “AS AVAILABLE” basis. Neither Plan nor
Administrator will be liable for any delay, difficulty in use, inaccuracy or incompleteness of information,
computer virus, malicious code, loss of data, compatibility issues, or otherwise. Plan and Administrator
will not be liable for any direct, indirect, incidental, consequential, or punitive damages arising out of
the Business Associate’s use of, or access to, the Service, or any link provided to another site, even if
Plan or Administrator was advised of the possibility of such damages, or even if such damages were
foreseeable.
Ownership, License and Restrictions on Use of Materials
All rights, title and interest (including all copyrights, trademarks and other intellectual property rights)
in the Service belong to the Plan or Administrator. In addition, the names, images, pictures, logos, and
icons are proprietary marks that belong to the Plan or Administrator. Except as expressly provided
below, nothing contained herein shall be construed as conferring any license or right, by implication,
estoppels or otherwise, under copyright or other intellectual property rights.
The Business Associate is hereby granted a nonexclusive, nontransferable, limited license to view and
use information retrieved from the Service solely in connection with its obligations under state and
federal law, including court orders, for the provision of judicial and/or health care services to Plan
members/enrollees.
Except as expressly provided above, no part of the information in or about the Service, including but
not limited to materials retrieved from it and the underlying code, may be reproduced, republished,
copied, transmitted, or distributed in any form or by any means. In no event shall materials from
this site be stored in any information storage and retrieval system without prior written permission
from Administrator or Plan.
Business Associate’s use of the site allows Plan and Administrator to gather certain limited information
about the Business Associate and its usage of the Service. Business Associate agrees and consents to
the use of such information in aggregated form.
Site System Integrity
The Business Associate may not use any device, software routine or agent to interfere or attempt to
interfere with the proper working of the Service. The Business Associate may not take any action which
imposes an unreasonable or disproportionately large load on Administrator’s or Plan’s infrastructure.
The Business Associate may not disclose or share its password to or with third parties, or allow its
password to be used, for any unauthorized purpose. The Business Associate shall take reasonable
precautions to secure its password from any unauthorized use. The Business Associate may not
attempt to log in with a username or password other than its own. The Business Associate shall
Business Associate Web Portal Agreement
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require its Primary Representative and Authorized Representative to take the same precautions and
follow the same requirements identified in this Agreement.
Continuous, uninterrupted access to the Service is not guaranteed. Numerous actions beyond our
control may interfere with the Service.
Confidential Information
“Confidential Information” is any information that identifies a member and relates to the member’s
participation in a Plan, the member’s physical or mental health or condition, the provision of health
care to the member, or payment for the provision of health care to the member. Confidential
information includes, without limitation, “individually identifiable health information,” as defined in 45
C.F.R. § 160.103 of HIPAA and “non-public personal information,” as defined in laws or regulations
promulgated under the Gramm-Leach-Bliley Act of 1999.
Business Associate acknowledges that Administrator or Plan will provide confidential information to
Business Associate solely for those Business Associate’s uses expressly defined herein. Business
Associate agrees to comply with the Business Associate’s Agreement executed prior to or concurrently
with this Agreement.
Governing Law and Venue
The laws of the State of Arizona govern this Agreement, without regard to conflict of law principals,
and the Business Associate’s access to and use of the Service under this Agreement. The Business
Associate submits to the exclusive jurisdiction of the courts in the State of Arizona and waives any
jurisdictional venue or inconvenient forum objections to such court.
Before Business Associate may seek legal recourse for any harm Business Associate believes it has
suffered from use of the Service, Business Associate will give Plan or Administrator written notice
specifying the harm and allow Plan or Administrator thirty (30) days from the date of notice to cure the
harm. Business Associate must initiate any cause of action under this Agreement or related to the
Service within one (1) year after the claim has arisen or Business Associate is barred from pursuing any
cause of action.
Termination
Plan or Administrator may issue Business Associate a warning, temporarily suspend, or indefinitely
suspend, Business Associate’s access to the Service if, in the sole discretion of Plan or Administrator,
Business Associate breaches this Agreement. Notwithstanding the foregoing, Plan and
Administrator reserve the right to immediately suspend or deny, in their singular or joint
discretion, Business Associate’s access to all, or any portion of, the Service if required to do so to
prevent violation of law, court order, Government Sponsor requirement, or threat to the Service.
Business Associate acknowledges and agrees that Plan or Administrator may immediately bar any
further access to the Service. Business Associate agrees that neither Plan nor Administrator shall be
liable to Business Associate or any third-party for any termination of Business Associate’s access to the
Service.
Business Associate Web Portal Agreement
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Except where required to be maintained or retained by state or federal law, upon termination of this
Agreement, Business Associate agrees to destroy, as required by the BAA, all information and
materials, in any format or capacity, obtained or retained from the Service.
Notices
All notices that are required or permitted to be given by one party to the other in connection with this
Agreement shall be in writing to the addresses below:
If to Business Associate:
Notices shall be sent to the attention of the “Primary Representative” identified on the
first page.
If to the Plan:
Mercy Care
BA Web Portal Administration
4750 S. 44th Pl, Suite 150
Phoenix, AZ 85040
Email: BAWebPortal@mercycareaz.org
The person(s) signing this Agreement warrants that he or she has full authority to do so and that the
signature below binds the Business Associate, including the Business Associate’s owners, employees,
agents and representatives, on whose behalf the person below signs.
Accepted:
By:
Its:
Date:
Business Associate Web Portal Agreement
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Attachment A
Authorized Representative Roster
Name: Last, First Reason for Access Phone # and Email
Title
Vania Laguna Verify SMI designation and Phone: 602-372-0092
Legal Support Supervisor eligibility on defendants Email:
1 lagunav@mcao.maricopa.gov
Katherine Holt Verify SMI designation and Phone: (602) 372-0954
Legal Support Specialist eligibility on defendants Email:
2 holtk@mcao.maricopa.gov
Melissa Garcia Verify SMI designation and Phone: (602)372-2977
Legal Support Specialist eligibility on defendants Email:
3 Melissa.Garcia@mcao.maricopa.gov
Yvonne Arellano Verify SMI designation and Phone: (602) 372-0089
Legal Support Specialist eligibility on defendants Email:
4 nunezy@mcao.maricopa.gov
Denise Davila Verify SMI designation and Phone: (602) 372-0192
Quality Assurance Coordinator eligibility on defendants Email:
5 davilad@mcao.maricopa.gov
Attachment B
Business Associate Web Portal Agreement
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BUSINESS ASSOCIATE AGREEMENT
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Business Associate Web Portal Agreement
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