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Run: Dental Business Associate Agreement Tracking Form

Track dental business associate agreements for labs, imaging centers, and software vendors that handle PHI. Capture scope, renewal dates, review status, and ...

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Vendor and Requester Details

Vendor / Business Associate Name (required)

Vendor Type (required)

Requester Name (required)

Requester Email (required)

Department (required)

PHI Access and Service Scope

Will this vendor create, receive, maintain, or transmit PHI? (required)

Service Description (required)

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 (required)

Effective Date

Expiration / Renewal Date

Last Compliance Review Date

Renewal Owner

Security and Compliance Review

Security review completed? (required)

Signed BAA on file? (required)

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?

Yes No N/A

Approver Name

Approval Comments

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Email (required)

Your name (optional)

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