HIPAA Business Associate Agreement Request Form

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Please fill out the info below and we will send you a copy of an executable HIPAA Business Associate Agreement (BAA) for your signature.

Please note this form is for Healthcare Providers who intend to use any of the Patient Personal Upload Portals hosted at secureforpatients.com websites.

For more information, please visit https://secureforpatients.com/baa

If you have any questions, please contact us
via Email at contact@secureforpatients.com
via LiveChat at https://entrespace.com/chat

Legal Name of the Healthcare Organization (Covered Entity) *

Name and Title of the Authorized Representative *

Full name of the representative with full legal authority to bind the healthcare organization (Covered Entity) to the Business Associate Agreement (e.g., Jane Doe, Chief HIPAA/OSHA Compliance Officer)

Your Full Name *

Your Phone Number *

Mailing Address of the Healthcare Organization *

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