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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:
Business Associate Name
	Type of Service(s) provided
	First Point of Contact Title
	First Point of Contact First Name
	First Point of Contact Last Name
	First Point of Contact Address
	First Point of Contact Address Continued (if needed)
	First Point of Contact City
	First Point of Contact State
	First Point of Contact Zip
	First Point of Contact Phone
	First Point of Contact Phone Extension (if needed)
	First Point of Contact Fax
	First point of Contact Email
	Second Point of Contact Title
	Second Point of Contact First Name
	Second Point of Contact Last Name
	Second Point of Contact Address
	Second Point of Contact Address Continued (if needed)
	Second Point of Contact City
	Second Point of Contact State
	Second Point of Contact Zip
	Second Point of Contact Phone
	Second Point of Contact Phone Extension (if needed)
	Second Point of Contact Fax
	Second point of Contact Email
	Website URLOCR 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**
Image of Business Associate List sample template

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed March 31, 2016Back to top
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