Common Contracts
2 similar Business Associate Agreement contracts
ContractBusiness Associate Agreement • February 25th, 2021
Participating facility Name: Federal Medicare Provider #: Corporation/Organization Name (If applicable): Address: Phone: Administrators Name: Administrators Email Address: Survey Champion Name (if different than administrator): Survey Champion Email Address: Licensed Skilled Nursing Bed Count: Total number of Long-Stay Residents with a of BIMS 8+: OPTIONAL EMPLOYEE SURVEY: (check yes or no) ☐ Yes / ☐ No Total Number of Employees if surveying (Full / Part time):
2019 TennCare QuILTSS Survey Sign-Up AgreementBusiness Associate Agreement • November 27th, 2018
Total number of Eligible Residents: Must have a BIMS of 8 or above and have lived in the skilled nursing center for at least 100 days as of January 25, 2019:
