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 of services, renewal dates, and compliance review.

Vendor and Agreement Overview

• Vendor / Business Associate Name
• Vendor Type
• Services Provided
  Briefly describe the services covered by the BAA and whether the vendor creates, receives, maintains, or transmits PHI.
• Agreement Status

PHI Access and Scope

• Does this vendor create, receive, maintain, or transmit PHI?
• Types of PHI Involved
• How Does the Vendor Access PHI?
• Minimum Necessary Review Completed?
  Confirm that only the minimum necessary PHI is shared for the vendor's stated purpose.

Agreement Dates and Renewal Tracking

• Effective Date
• Execution Date
• Expiration / Renewal Date
• Does the agreement auto-renew?
• Renewal Notice Period (Days)
  Enter the number of days before expiration when renewal notice should be sent.

Compliance Review and Documentation

• Compliance Review Status
• Review Notes
  Document any concerns, required changes, or conditions for approval.
• Supporting Documents
  Upload the executed BAA, vendor security documentation, or related compliance records.
• Next Review Date

Contacts and Follow-Up

• Internal Owner / Department
• Next Action
• Follow-Up Due Date