Dental Business Associate Agreement Tracking Form

Tracks business associate agreements with dental labs, imaging centers, and software vendors that handle PHI, including agreement status, scope, renewal dates, and compliance review.

Vendor and Requester Details

• Vendor / Business Associate Name
• Vendor Type
• Requester Name
• Requester Email
• Department

PHI Access and Service Scope

• Will this vendor create, receive, maintain, or transmit PHI?
• Service Description
  Briefly describe the service and why the vendor needs access to PHI.
• PHI Categories Involved
• How does the vendor access PHI?
• Data Minimization Notes
  Describe any steps taken to limit PHI shared to the minimum necessary.

Agreement Status and Dates

• BAA Status
• Effective Date
• Expiration / Renewal Date
• Last Compliance Review Date
• Renewal Owner

Security and Compliance Review

• Security review completed?
• Signed BAA on file?
• Subcontractor / downstream vendor clause confirmed?
• Breach notification terms confirmed?
• Compliance Risk Level
• Review Notes
  Add any compliance concerns, exceptions, or follow-up actions.

Attachments and Approval

• Signed BAA Document
• Supporting Documents
• Requires compliance approval?
• Approver Name
• Approval Comments