Business Associate Listing - Sample Template

Phase 2 Audits: Request for Business Associate Listing

Selected auditees will be requested by OCR to identify and provide detailed information regarding their business associates.  The information collected by OCR will be used to help identify business associates for the Phase 2 audits.

The following is a list of the specific information that OCR is requesting.  Covered entities should provide the requested information to the best of their knowledge and include the name and types of services provided by each business associate.  Please include a secondary point of contact if that information is available.  Covered entities responding to the request should identify each element for each business associate.

Responsive Elements:

1. Business Associate Name
2. Type of Service(s) provided
3. First Point of Contact Title
4. First Point of Contact First Name
5. First Point of Contact Last Name
6. First Point of Contact Address
7. First Point of Contact Address Continued (if needed)
8. First Point of Contact City
9. First Point of Contact State
10. First Point of Contact Zip
11. First Point of Contact Phone
12.  First Point of Contact Phone Extension (if needed)
13. First Point of Contact Fax
14. First point of Contact Email
15. Second Point of Contact Title
16. Second Point of Contact First Name
17. Second Point of Contact Last Name
18. Second Point of Contact Address
19. Second Point of Contact Address Continued (if needed)
20. Second Point of Contact City
21. Second Point of Contact State
22. Second Point of Contact Zip
23.  Second Point of Contact Phone
24. Second Point of Contact Phone Extension (if needed)
25. Second Point of Contact Fax
26. Second point of Contact Email
27. Website URL

OCR has developed a template which covered entities may find helpful to use when responding to the business associate list request.  Selected auditees may, but are not required, to use the following template.

Sample Template for Business Associate Listing