Contract Period: to Agency: Certification: We certify that the information contained in, or attached to, this contract document is accurate and complete. __________________________________ ________________________ Chair, Board of Directors Date (Original signature) __________________________________ ________________________ Executive Director Date (Original signature) Please List Authorized Signatories for contract documents, checks, and invoices: (List full name and title) Name Title Name Title Name Title STANDARDIZED BOARD RESOLUTION FORM page 2 of 2 – The Board endorses the following commitments as defined in this document: Health Insurance Portability and Accountability Act (HIPAA)* Specific to (Health Insurance Portability and Accountability Act), the above noted Provider Agency is deemed a covered entity and must submit the required Business Associate Agreement.
Contract Period: to Agency: Certification: We certify that the information contained in, or attached to, this contract document is accurate and complete. __________________________________ ________________________ Chair, Board of Directors Date (Original signature) __________________________________ ________________________ Executive Director Date (Original signature) Please List Authorized Signatories for contract documents, checks, and invoices: (List full name and title) Name Title Name Title Name Title STANDARDIZED BOARD RESOLUTION FORM – page 2 of 2 The Board endorses the following commitments as defined in this document: Health Insurance Portability and Accountability Act (HIPAA)* Specific to (Health Insurance Portability and Accountability Act), the above noted Provider Agency is deemed a covered entity and must submit the required Business Associate Agreement.
reap_annexa.docx