SkySwitch HIPAA BAA Worksheet

SkySwitch HIPAA BAA Worksheet
If you provide phone service to heathcare providers in the United States, then HIPAA Privacy Rules require you to provide a Business Associate Agreement ("BAA") to your customers ("Covered Entities"). As a potential recipient of your customers' protected health information, SkySwitch is required to provide you with a Business Associate Agreement as well. SkySwitch will not provide a BAA to your customers.

The purpose of this form is to collect information that will be used to create a BAA between SkySwitch and your organization. After submitting the form, please expect to receive a BAA for electronic signature.
Reseller ID*
Legal Name of Organization (to be used in BAA)*
Country of your Company's Business Registration*

CanadaUS
Address 1*
Address 2
City*
Province*
Postal Code*
State*
Zip Code US*
ZIP Code*
Web Site
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
Compliance Contact First Name*
Compliance Contact Last Name*
Compliance Contact Email Address*
example@example.com
Should be Empty: