Common Contracts
2 similar Business Associate Agreement Addendum contracts
Business Associate Agreement AddendumBusiness Associate Agreement Addendum • November 19th, 2019
Facility’s Name (“Facility”): ABC Facility Address: 123 Main Street, Ellicott City, MD 21043 Legal Structure: &RUSRUDWLRQ Owner’s Name: (In the event accreditation is granted, the entity that owns and operates the Facility) John Doe Owner’s Main Business Address: 123 Main Street, Ellicott City, MD 21043 Owner’s Representative Name & Title: (Should be the person for day-to-day contact and does not need to be the signee of the Agreement.) Jane Doe, Medical Director Private (non-governmental) Facility? Yes No Governmental Facility? Yes No Federal Tax ID: 123456789
Business Associate Agreement AddendumBusiness Associate Agreement Addendum • November 19th, 2019
Facility’s Name (“Facility”): ABC Facility Address: 123 Main Street, Ellicott City, MD 21043 Legal Structure: &RUSRUDWLRQ Owner’s Name: (In the event accreditation is granted, the entity that owns and operates the Facility) John Doe Owner’s Main Business Address: 123 Main Street, Ellicott City, MD 21043 Owner’s Representative Name & Title: (Should be the person for day-to-day contact and does not need to be the signee of the Agreement.) Jane Doe, Medical Director Private (non-governmental) Facility? Yes No Governmental Facility? Yes No Federal Tax ID: 123456789
