CM-09-12-238titlairtoe 3 /1urbotttort i
ker
THIS Arreemont fs orrtnrod into on 11119day �� P)
'ENTTIY crud ,
of bo �� � n�_�-_�5 u iv C �
( ) (.1!_t//r'f'/nL �i
(ASSOCIATE ).T
>,'~'HERE.AS, ENTITY is.a'covered entity' as that ten is defined in Health lnsuranc Portability end
Accountability Act Privtoy Regulation, (`Privacy Regulation`) veil make rtvallabla to ASSOCIATE:
certain Information that is confidential and must bo afforded special troa wont and protection.
WHEREAS, ASSOCIATES will havo access to and/or receive from ENTITY wrtoin protected health
Information that can bo used or disclosed only as permitted by the Health Insurance Portability and
Accountab✓lity Act of 19f18, and the Rules and Regulations enacted with respect thereto, as the
sana0 may be roaonclod regarding privacy of iradIvlctual Identifiable health Infcrmatkn. In additicxa to
agreements with ENTITY, ASSOCIATE may also have additional agreements written or verbal with
ENTITIES sponsor,
NOW, THEREFORE, ENTITY and /ASSOCIATE agr3o as follows:
i. Tho term of t hes Contr;actshah corn -aorta as of -,-J� (tiro `Effective Date'), and shall
oxpn-et Men all of ttw Infprmalion provided by ENTITY to ASSOCIATE is destroyed or returned to
ENTITY.
2. Tho Parties hereby agree that ASSOCIATE shah tea permitted to use and/or disclose Information
provided or mado aval,'ablo from ENTITY for the following stated purposes:
a. Assistance In treatment, payment or health can operations of ENTITY.
b. A.%istanw In analyzing and dotornrininp the fiscd status of ENTITY,
c. Assistance in delomainir>g utilization, affect of benefit ciaangos, and nmanr.{;r:munt of o!hor
business rassocietes of ENTITY,
d. Assistance In dotarminflfj tho naafi of 8orvices, 'iefjc': atinij u:aa oc v rtilo od to
ENTITY Including the plating of Insurance po!kdos, mann ement of such 1kolic o:r and
rnonitoriof] porfommarrco and offocfi onoss of such sery acs.
o. ASSOCIATE shal not engage In raor permit Eho use of protected health Information for The
purpose of taking employment action against any member raveled by ENTITY.
3. ASSOCIATE OBLIGATIONS:
a. ASSOCIATE hereby afjreos that the Information provided or made ava'ahio by ENTITY shall not
be furthor used or d>rdosod other than as permitted or required by the Contract or as required by
lave, and that ASSOCIATE will use oppropflate safeguards vlaon hancksj protected health
Infonnotion.
b. ASSOCIATE hereby agrees that ft shall report to ENTITY any use or disclosure of information
not provided for or aiiovM by tills Contract,
c. ASSOCIATE hereby agrees that anytimo Information fs provided or mode avetfie to any
subcontractors or Ggonts, ASSOCIATE must enter Into a subcontract with trio subcontractor or
agent that contains substantially the same terms, conditions and restrictions on the use aced
disclosure of Infonaaiion as contained In this Contract.
c %►\- c -is-06
d, ASSOCIATE hereby agrees to miiko avallaltle and provl(So n tight of ucceM to information by nil
Individual, to make Info ma(ioa avafablo for a mandr11ent End to Incorporate any a ioncimentti io
Informallon, and to provldo all acimintlau of disclosures lti accorcfanra vitt!) U e Piivtrcy RA).
o. ASSOCIATE hereby egroas to'mike its Inton mal prectkes, books, and tocords rotating to the use
or disclosure of Information received from, or crtiatocl or r:v(;olved by ASSOCIATE on bsl iaif of Ute
ENTITY, Y, avaflabla to EMITIS for pripo sos of dotan iln!ng coinpl!anca of ENTITY v401 Umo of i! IS
Prhraey Regulations.
f,
ASSOCUkTE aciteos to hc+vo procoduros In place for mitigating, to U'o rnaxlrrtuiu coPent
prnclicablo, any delototfous offoct croft] tho use orcifrclosurr of infornmatIon in a mrmannur conlraiy to
Mia Contract or Ma 1}NI IS Privacy RogtraEiaas.
4. ASSOCIA i is agreas. that ENTITY hes Ma right to terminaln iid3 Af)roernont anti ;ra k rr!laf If
PPI; UY datoratinaa Mat ASSOCIATE ii<i3 violated Mk; AfJlowf'eiit 08(1 is trntmt,!O to :,rw!k;?a1o,
ractify or olisstv;isrr fail:' o piovklo t;rlcqua;o a° sumnco of COIreCiivo tsGUr;;l to plownt fu. -iter
inripprepriate clisclo uns;r,
IN WITNESS WHET OP, O ff: and ENTITY have caused tills Cootroct to be sed ad
dcllvared by fho!r d fepresontajvos, as of the dato not fol abovo,
ASSOC A'r
Print Nana: ,c y/ J/A„Ucl� fj
ENT
Printf , c1o�Me YR,t�TUiS .
Title; '
Date ..!nem: rt -4, O --
OF ROUND ROCK, TEXAS
POR CITY, ATTEST:
By:
Sara L. ?Mite, c7ty Secretary
P'OR CITY, PROVED AS TOPORN:
r/°._
Step la L. Sheets, City Attorney
DATE: 11/24/09
SUBJECT: City Manager Approval — 12/4/09
ITEM: Consider executing the Business Associate Agreement with Whiteglove
House Call Health
Department:
Staff Person:
Human Resources
Teresa Bledsoe, Human Resources Director
Justification: Whiteglove House Call Health's Business Associate Agreement
represents and warrants that it will comply with all privacy regulation as defied in the
Health Insurance Portability and Accountability Act Privacy Regulations when handling
any and all protected health information of employees covered by the City's health plan.
Strategic Plan Relevance:
Funding:
Cost:
Source of funds:
Outside Resources (if applicable):
Public Comment (if applicable):
10 19 09
Request for City Council/City Manager Action
rr i City Council City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Human Resources
Contact Person: Teresa Bledsoe / Linda Gunther
Project Mgr/Resource: Teresa Bledsoe
Project Coordinator: Linda Gunther
Assigned Attorney: l K Gayle
City Council or City Manager Approval Date:
Agenda Wording
Project Name:
ContractorNendor:
Funding Source:
Additional funding Source:
Amount:
Account Number:
12/4/2009
FoRgrcfg afio l7se ONLY
DEC 0 2 2009 rnnra.
Received:
Tag#:
Original Documents Received:
Business Associate Agreement
Whiteglove House Call Health
Consider executing the Business Associate Agreement with Whiteglove House Call Health
Finance Information
Is Funding Required?
Yes No I
Initial Construction Contract
Construction Contract Amendment a
Change Order g
[]Change in Quantity ED Unforeseen Circumstances
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Other (Please clearly identify action below)
FINANCE
N/A Approved
1::=1 El
0
[3 [2]
APPROVALS
(to be completed ONLYby Finance)
Final Finance Approval Required
Approved
Finance/CIP L. Olsen Date 12/1/2009
Finance/Acct E. Wilson Date 12/2/2009
Purchasing EE Bowden. Date 11/25/2009
Budget P. Bryan
Amount
12/2/2009
Date
Once approvals have been obtained, please forward the RFA, blue sheet, back up information and originals to City Secretary, Sara White.
ITEMS WILL NOT BE PLACED ON THE COUNCIL AGENDA WITHOUT FINANCE AND LEGAL APPROVAL PRIOR TO SUBMISSION.
Reuired for Submission of ALL Ci Council and Ci a. er Items
Project Mgr. Sig Ir �" /1/y'/� 4
Dept. Director Signa/!
'City AttorneySignatura�
City Manager Signature:
Date: I - Li" 09
Date: 12-x-01
*City Attomey signature is required for all items.
REVISED 12/2/2009
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: HUMAN RESOURCES Project Name: BUSINESS ASSOCIATE AGREEWIENI
Project Mgr/Resource: LINDA GUNTHER Contractor/Vendor: WHITEGLOVE HOUSE CALL HEALTH
Council Action:
ORDINANCE RESOLUTION
Agenda Wording
City Manager Approval
CMA Wording
Consider executing tile Business Associate Agreement with Whiteglove House Call Health.
Attorney Approval
Attorney
Notes/Comments
Date
0:1v,cfox1SCCInIs10 ) 24\ 09011MISCIOO 176332
Updated wJioiu