Health Insurance Portability & Accountability Act (HIPAA) Data Collection: of health care components must be identified. All identified business associates must be reported to Business Associates the of the appropriate health care component for tracking. Please respond to the questions below to Privacy Coordinator facilitate the compliance. Does contractor create, receive, transmit, or store Patient Health Information (PHI) on Yes No behalf of the University for Services provided under this contract? What does the contractor do with the PHI on behalf of the University? (Check all that apply) Transmit Receive Electronic Oral Paper Electronic Oral Paper Create Maintain Electronic Oral Paper Electronic Oral Paper Are the contractor Are the University Is any PHI maintained in a Will the Service be performed in Transactions and unit’s Transactions and Minnesota? designated record set Code Sets (TCS) Code Sets (TCS) (medical record)? complaint with complaint with Electronic Data Electronic Data Interchange (EDI) Interchange (EDI) PHI PHI billing billing standards? Standards? Yes No Yes No Yes No Yes No Is this person a If YES (person is Is this an entertainer (that If YES answered on the above resident of resident of Michigan, is, musician, singer, dancer, Entertainer question, is this person Michigan, North North Dakota, or comedian, thespian, a public speaker? Dakota, or Wisconsin), is form professional athlete, Wisconsin? MW-R (reciprocity) lecturer, or public speaker completed? in a noncredit program setting)? Yes No Yes No Yes No Yes No Has the service provided filed a W-4 claiming exemption from Minnesota withholding, Yes No or reduced withholding?
Health Insurance Portability & Accountability Act (HIPAA) Data Collection: Business Associates of health care components must be identified. All identified business associates must be reported to the Privacy Coordinator of the appropriate health care component for tracking. Please respond to the questions below to facilitate the compliance. Does contractor create, receive, transmit, or store Patient Health Information (PHI) on behalf of the University for Services provided under this contract? Yes No What does the contractor do with the PHI on behalf of the University? (Check all that apply) Transmit Receive Electronic Oral Paper Electronic Oral Paper Create Maintain Electronic Oral Paper Electronic Oral Paper Are the contractor Transactions and Code Sets (TCS) complaint with Electronic Data Interchange (EDI) PHI billing Standards? Are the University unit’s Transactions and Code Sets (TCS) complaint with Electronic Data Interchange (EDI) PHI billing standards? Is any PHI maintained in a designated record set (medical record)? Will the Service be performed in Minnesota? Yes No Yes No Yes No Yes No Is this person a resident of Michigan, North Dakota, or Wisconsin? If YES (person is resident of Michigan, North Dakota, or Wisconsin), is form MW-R (reciprocity) completed? Is this an entertainer (that is, musician, singer, dancer, comedian, thespian, professional athlete, lecturer, or public speaker in a noncredit program setting)? If YES answered on the above Entertainer question, is this person a public speaker? Yes No Yes No Yes No Yes No Has the service provided filed a W-4 claiming exemption from Minnesota withholding, or reduced withholding? Yes No
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