Attachment D.5 - Business Associate Agreement

Business Associate Profile Application
INSTRUCTIONS: The Profile Application asks questions concerning the relationship between your company and the Veterans Health Administration (VHA), and the privacy and security of VHA data required by your company to provide all contracted services. Please provide thorough and complete responses and ensure that appropriate company officials with knowledge of privacy and security controls assist with completing, signing, and dating this profile and return to the Privacy Office @ [email protected]. If you have questions about the Profile Application, please email the Privacy team at the same email.

Company Demographic Information
Questions 1-10a ask important demographic information about your company. 1. Please provide your company’s official name, d/b/a, address, website, and UEI #. Note: Your company’s UEI # can be found within your contract or on www.SAM.gov. Company Name:
d/b/a:
Address:
Website:
Unique Entity
Identifier (UEI) #:
2. Please provide the addresses of all other/alternate locations where VHA Data is used, processed, accessed, created, stored, transmitted (other than telework locations). Note: This question is asking about all the locations where operations using VHA PII/PHI take place within your company. Address 1:
Address 2:
Address 3:
3. Please provide names and contact information (phone, cell, email) for the following positions in your company:
Privacy Officer:
Information Security
Officer:
Compliance Officer:
Records Manager:
Other:

Profile Application, January 2025

Other:
Questions 5-7 ask about your company’s status as a healthcare provider, whether or not your company provides treatment, and whether your staff are considered VHA workforce members based upon your company’s underlying agreements with the VA/VHA.
5. Under the terms of your contract with VHA, does your company act as a health care provider as defined by the HIPAA Regulations at 45 CFR §160.103?

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

8. Has your company changed names or undergone a novation since the last 2-year review of your BAA? If “Yes”, please provide your company’s previous name below.

☐ Yes

☐ No

9. Is your company as listed in question 1 of this profile application a wholly owned subsidiary of another company? If “Yes”, please provide the name of the parent company below.

☐ Yes

☐ No

10. Has your company been purchased or merged with another company since the last 2-year review of your BAA? If “Yes”, please tell us what company purchased or