1st Business Associate Addendum 05/21/2003
Gled( of Ihe
Cimul coun
Danny L. Kolhage
Clerk of the Circuit Court
Phone: (305)292-3550
FAX: (305) 295-3663
e-mail: phancock@monroe-clerk.com
Memorandum
TO: Fire Chief Clark Martin
Fire-Rescue Department
ATTN: Susan Hover
FROM: Pamela G. Hanco~
Deputy Clerk e....y
DATE: June 12, 2003
At the May 21, 2003, Board of County Commissioner's meeting the Business Associate
Addendum between Monroe County, Advance Data Processing, Inc. (ADPI) and Second Review,
Inc. to ensure that ADPI is carrying out its obligation under the Health Insurance Portability and
Accountability Act (HIP AA) which protects the privacy of protected health insurance information
of patients that are being bill by ADPI for Monroe County.
Enclosed is a duplicate original of the above-mentioned for your handling. Should you
have any questions please feel free to contact our office.
cc: County Administrator w/o document
County Attorney
Finance
File ""
Business Associate Addendum
Advanced Data Processing, Inc. and Second Review, Inc.
(hereinafter collectively referred to as "Business Associates") and Monroe
County hereby amend the Agreement entered into on September 1, 2000,
("the Agreement") by adding the following additional language to the
Agreement.
1. ADPI shall carry out its obligations under this Addendum in
compliance with the privacy regulations pursuant to Public Law
104-191 of August 21, 1996, known as the Health Insurance
Portability and Accountability Act of 1996, Subtitle F -
Administrative Simplification, Sections 261, et seq., as amended
("HIPAA"), to protect the privacy of any personally identifiable
protected health information ("PHI") that is collected, processed or
learned as a result of the Billing Services provided hereunder. In
conformity therewith, Business Associates agree that they will:
a. Not use or further disclose PHI except as permitted under this
Addendum or required by law;
b. Use appropriate safeguards to prevent use or disclosure of PHI
except as permitted by this Addendum;
c. To mitigate, to the extent practicable, any harmful effect that is
known to Business Associates of a use or disclosure of PHI by
Business Associates in violation of this Addendum.
d. Report to Monroe County any use or disclosure of PHI not provided
for by this Addendum of which Business Associates become aware;
e. Ensure that any agents or subcontractors to whom Business
Associates provide PHI, or who have access to PHI, agree to the
same restrictions and conditions that apply to Business Associates
with respect to such PHI;
f. Make PHI available to Monroe County and to the individual who
has a right of access as required under HIPAA within 30 days of
the request by Monroe County regarding the individual;
g. Incorporate any amendments to PHI when notified to do so by
Monroe County;
h. Provide an accounting of all uses or disclosures of PHI made by
Business Associates as required under the HIPAA privacy rule
within sixty (60) days;
1. Make their internal practices, books and records relating to the use
and disclosure of PHI available to the Secretary of the Department
of Health and Human Services for purposes of determining
Business Associates' and Monroe County's compliance with HIPAA;
and
J. At the termination of the Agreement, return or destroy all PHI
received from, or created or received by Business Associates on
behalf of Monroe County, and if return is infeasible, the
protections of this Addendum will extend to such PHI.
2. The specific uses and disclosures of PHI that may be made by
Business Associates on behalf of Monroe County include:
a. The preparation of invoices to patients, carriers, insurers and
others responsible for payment or reimbursement of the services
provided by Monroe County to its patients;
b. Preparation of reminder notices and documents pertaining to
collections of overdue accounts;
c. The submission of supporting documentation to carriers, insurers
and other payers to substantiate the health care services provided
by Monroe County to its patients or to appeal denials of payment
for same.
d. Uses required for the proper management of Business Associates
as business associates.
e. Other uses or disclosures of PHI as permitted by the HIPAA privacy
rule.
3. Notwithstanding any other provisions of this Addendum, the
Agreement may be terminated by Monroe County if ADPI has
violated a term or provision of this Addendum pertaining to ADPI's
material obligations under the HIPAA privacy rule, or if ADPI
engages in conduct which would, if committed by Monroe County,
result in a violation of the HIPAA privacy rule by Monroe County.
2
IN WITNESS WHEREOF, each of the undersigned has caused this
Addendum to be duly executed in its name and on its behalf effective as
of April 14, 2003.
Monroe ~<t~~, I[l<~rida / /
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Title: IVl A Y f)(~
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Client#: 15220 ADVADAT
ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(M03DNYYY)
04/14/
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Hamilton Dorsey Alston Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
4401 Northside PkwySuite 400 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Atlanta, GA 30327-3078
770 850-0050 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: FCCI Insurance Company
Advanced Data Processing, Inc. INSURER B: Illinois Union Insurance Company
520 NW 165th Street Road INSURER C:
Suite 201 -
INSURER D:
Miami, FL 33169-6303
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AMYL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR INSRC DATE(MM/DD/YY) DATE(MM/DD/YY)
A GENERAL LIABILITY CPP00019S5 10/10/02 - 10/10/03 EACH OCCURRENCE $1,000;000
DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000
CLAIMS MADE X OCCUR MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000
— POLICY n MT- n LOC
JEC
A AUTOMOBILE LIABILITY CA0002425 10/10/02 10/10/03 COMBINED SINGLE LIMIT $1,000,000
ANY AUTO (Ea accident)
ALL OWNED AUTOS • BODILY INJURY
SCHEDULED AUTOS (Per person) $
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) •
$
X Hired Car PD $100 Comp.
Deductibles: $250 Collision PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS/UMBRELLA LIABILITY UMB00001097 10/10/02 10/10/03 EACH OCCURRENCE $2,000,000
X OCCUR CLAIMS MADE AGGREGATE $2,000,000
$
DEDUCTIBLE $
RETENTION $$1 O,000 $
A WORKERS COMPENSATION AND 001WCO2A5 1763 - - - 10/10/02 10/10/03 WC STATU- OTH-
TORY LIMITS — ER-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
B OTHER Errors & BM120003667 10/10/02 10/10/03 $2,000,000 Occ/Agg
Omissions ��(� $25,000 Retention
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES lM �j ' b IVlti CIAL PROVISIONS peg
ECEIVED
BY
r0
DATE APR 2 9 2003
WAIVER NIA ~VEE BY:
r►RE HtscuE ---�
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Monroe County BOCC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Attn: Darice;Room 268 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
1100 Simonton St. - Room 268 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Key West, FL 33040 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
/
%
ACORD 25(2001/08) 1 of 2 #5159805/M152419 CMW o ACORD CORPORATION 1988