Request a new Business Associate (BA) Agreement

To request a new Business Associate Agreement ("BAA"), please complete the form below and press submit. A copy of the underlying contract with the proposed vendor is required to be uploaded with your request. If you have a copy of the vendors proposed BAA, please upload a copy with your request. Fields with an asterisk (*) are required.

The USF Privacy & Healthcare Civil Rights Compliance Department will contact you if we need further information and let you know when this process has been completed. Typically, the turnaround time on getting a signed BAA in place (depending on language request changes) is 14 business days. All BAA requests are reviewed and processed in the order that they are received. Please let us know if this is a rush so we can determine if a quicker turnaround time is possible. If you have questions, please contact us at 813-974-2222 or email our office at Privacy@usf.edu

Thank You

* = Required Field

Business Information

Name of Business Associate (BA) *

If this BA will be associated with one specific facility, select it here. Otherwise, leave blank

BA Type - select the most appropriate choice *

Provide a brief description of the services provided by this BA that involves the use, transmittal or storage of PHI *

BA Website Address (optional)

Contacts

Primary Contact * (used for legal notification)

Name *

Title / Dept

Email *

Phone number *

Fax number

Address

Secondary Contact (optional)

Name

Title / Dept

Phone number

Fax number

Address

Business Associate Agreements

Provide any additional information about this BA or BA Agreement (optional)

Requested By

Enter "N/A" if not applicable

Name *

Email *

Phone Number *

Title / Dept *