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Title: Disclosures of Personally Identifiable Health Information to Business Associates
Subject: Office of Compliance & Corporate Integrity (OCCI)
Policy No: OCCI:2013:P08
Applies: RowanSOM
Issuing Authority: Chief Audit, Compliance & Privacy Officer; Director of Information Security
Responsible Officer: Chief Audit, Compliance & Privacy Officer; Director of Information Security
Date Adopted: 07/01/2013
Last Revision: 03 01/2526/20202021
Last Reviewed: 0301/2526/20202021


To assure compliance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 2004, Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the Omnibus Privacy Final Rule of 2013 in relation to disclosures of Protected Health Information (PHI) and to entering into contracts with business associates.


  1. Attachment 1, Is a Person or Entity a "Business Associate" and Required to Enter Into a Written Business Associate Contract?
  2. Attachment 2, Examples of Potential Business Associates
  3. Attachment 3, Treatment, Payment and Health Care Operations
  4. Attachment 4, Business Associates Agreement Involving the Access to Protected Health Information


Any individual who violates this policy shall be subject to discipline up to and including dismissal from the University in accordance with their union and University rules.  Civil and criminal penalties may be applied accordingly.  Violations of this policy may require retraining and be reviewed with employee during the annual appraisal process. The Deans of each College, Vice Presidents, and University President, with the assistance of the Department of Human Resources, will enforce the sanctions appropriately and consistently to all violators regardless of job titles or level within the University and in accordance with bargaining agreements for represented employees. Any sanction costs or fines will be borne by the Department and the Department Chair or VP will determine how these funds will be assigned.

By Direction of the President: