Omnibus Rule Business Associate Agreement

As a Business Associate/Vendor of St. Luke’s Health System, Ltd., please download the Business Associate Agreement (BAA) template, complete and return it to St. Luke’s Compliance Department.

Instructions

  1. On Page 1, “fill in the Business Associate name including type of applicable corporation (Inc., Ltd, LLC, etc.)” with your organization’s full legal name or the person’s name that is providing services to St. Luke’s.
  2. On Page 1, “fill in the State of incorporation and profit/nonprofit status (Idaho nonprofit or for-profit corporation, etc.)” (if applicable).
  3. On Page 1, “fill in your company’s principal office address located at (Street, city, state, zip).”
  4. On Page 1, in the Background section, “fill in the services your organization or person will be doing on behalf of St. Luke’s.”
  5. In clause 19, fill in the current date as the Effective Date.
  6. On Page 6, fill in the Business Associate signature block information and the Operational Contact (2nd contact).
    • Sign (your electronic signature will be accepted as the original)
    • Print Name
    • Print Title
    • Email Address
    • Phone Number
    • Fax Number
    • Web Site URL
    • Date
  1. Scan and return the BAA to Nancy Tema-Cotton at [email protected]

If you prefer, you may print, complete, and sign the BAA in pen. If you do so, please return a copy by mail to:

Attn: Nancy Tema-Cotton
St. Luke’s Health System
190 E. Bannock Street, Boise, ID, 83712

Or fax a copy to: (208) 493-0572

Please contact Nancy Tema-Cotton, Compliance Analyst at (208) 493-2496 or our Privacy Officer at (208) 493-0383 with questions.