Village Green Apothecary
DATA USE AGREEMENT
We, the Village Green Apothecary (.VGA.) and Salugenecists, Inc. (.Salugenecists.), hereby agree to be bound by the terms of this Data Use Agreement (the .Agreement.) to the extent that (a) you are an individual who is applying for certification or recertification by VGA as a xxxxxxx Practitioner and (b) in connection with that application, you provide one or more case reports containing Protected Health Information to VGA in a Limited Data Set using a template provided by VGA on a website developed and/or operated by Salugenecists.
By submitting case reports to VGA, you also agree to be bound by the terms of this Agreement.
This Agreement supersedes and replaces any prior data use agreement we sent to you or posted on our website(s). Capitalized terms used in this Agreement shall have the meanings given them in the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended (.HIPAA.) and the Health Information Technology for Economic and Clinical Health Act and its implementing regulations (the .HITECH Act.).
For the purpose of applying for certification or recertification by VGA as xxxxxxxxxx, you may provide VGA patient case reports that contain Protected Health Information consisting of dates that are relevant to the treatment of the patient, including but not limited to the patient.s date of birth, dates of medically significant events, and dates of patient encounters (the .Limited Data Set.). You agree that such case reports will be submitted using an VGA-provided template, will not contain any Protected Health Information that is not requested by VGA in the template, and specifically will not include any of the following identifiers of the individual(s) who is (are) the subject(s) of the Protected Health Information, or of relatives, employers or household members of the individual(s):
postal address information, other than town or city, state and zip code;
electronic mail addresses;
social security numbers;
medical record numbers;
health plan beneficiary numbers;
vehicle identifiers and serial numbers, including license plate numbers;
device identifiers and serial numbers;
Web Universal Resource Locators (URLs);
Internet Protocol (IP) address numbers;
biometric identifiers, including finger and voice prints; and
full face photographic images and any comparable images.
VGA may use and disclose the Limited Data Set received from you only in connection with its performance of the following Health Care Operations: Evaluation of your request for certification or recertification as a VGA Practitioner and any subsequent actions taken by
VGA with respect to your certification or recertification (including without limitation any appeal of a denial of certification or recertification). VGA will not use or further disclose the Restricted Data other than as expressly permitted or required by this Agreement or as Required by Law.
In receiving the Limited Data Set hereunder, Salugenecists is acting as a subcontractor of VGA. Salugenecists may only use and disclose the Limited Data Set received from you for the purpose of forwarding it to VGA. Salugenecists will not use or further disclose the Restricted Data other than as expressly permitted or required by this Agreement or as Required by Law.
We will not use or disclose the Limited Data Set in a manner that would violate HIPAA regulations or the HITECH Act if done by you.
We will use appropriate safeguards to prevent use or disclosure of the Limited Data Set other than as provided for by this Agreement.
We will report to you any use or disclosure of the Limited Data Set not provided for by this Agreement of which we become aware.
We will ensure that any agent, including any subcontractor, to whom we provide the Limited Data Set agrees to the same restrictions and conditions that apply through this Agreement to us with respect to such information.
We will not attempt to identify or contact any individual represented in the Limited Data Set.
Nothing in this Agreement is intended to, or does, confer upon any other person or entity any rights, remedies, obligations, or liabilities whatsoever.
We may amend this Agreement by posting amendments on our website. The amendments will become effective upon posting.
Signed: Village Green Apothecary
Effective: January 24, 2013