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POLICY NO: 8009
EFFECTIVE DATE: 11/01/06
REVISED DATE: 07/01/11
REVIEWED DATE: 07/01/11

Basis for Policy

• Section 6.4 of the Bylaws of the Board of Regents (BOR) of the University of Nebraska Board of Regents Policy on Administrative Approval of University Contracts (RP – 6.3.1)
• University of Nebraska Executive Memorandum 13, Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions
• University of Nebraska Executive Memorandum 14, Delegation of Administrative Authority to Approve Certain Types of University Contracts, and Requirements for Submittal and Execution of Contracts Requiring Approval by the Board of Regents
• University of Nebraska Executive Memorandum No. 26, Information Security Plan
• University of Nebraska Executive Memorandum No. 27, HIPAA Compliance Plan
• Health Insurance Portability and Accountability Act of 1996 (HIPAA) [45 CFR §164.502(e)(1)]
• Gramm-Leach-Bliley Act (GLBA) [12 CFR §225.28]

Policy

Written Agreements Required. All organizations and individuals that provide products and services to the University of Nebraska Medical Center (UNMC) shall enter into a written contract with UNMC. Pursuant to University of Nebraska Executive Memorandum No. 14, the President has delegated authority to each Chancellor to approve specific types of contracts described in Section 4 of RP -6.3.1. Pursuant to University of Nebraska Executive Memorandum No. 13 and Executive Memorandum No. 14, the Chancellor may delegate contract signature authority. Individuals with the authority to sign contracts on behalf of UNMC are listed in the Contract Signature Authority Table. (Changes to the Contract Signature Authority Table should be forwarded to the Director, Financial Compliance and Cost Analysis.)

Original contracts are maintained as follows:

Student and Academic Program Affiliations:	Vice Chancellor for Academic Affairs Office
Externally funded projects, including grants, contracts, cooperative agreements, subcontracts and other subrecipient & vendor agreements:	Sponsored Programs Administration
Continuing Medical Education Program Agreements:	Center for Continuing Education
All Others:	Business Services

Independent Contractors

Independent contractors are 3rd parties who perform services for or provide products to UNMC who are neither employees nor volunteers. The Independent Contractor Agreement Template shall be used when entering into contracts with independent contractors who perform non-clinical services (with the exception of sponsored programs agreements and continuing medical education program agreements). For clinical service agreements, contact UNMC Physicians (UNMC-P) or University Dental Associates (UDA) administration, as applicable. Questions regarding independent contractor status or requests to modify the template shall be directed to the Associate General Counsel for Health Care, Business Services, or Sponsored Programs Administration (for grants or sponsored programs agreements).

• (A) Use of Protected Health Information (PHI) by an Outside Entity

When a person or entity outside UNMC, The Nebraska Medical Center, UDA and UNMC-P performs a function or activity on behalf of UNMC that involves the use or disclosure of protected health information (PHI), the person or entity is a business associate of UNMC and a business associate addendum must be added to the contract for HIPAA compliance. Health care providers providing treatment are exempt from the business associate requirement.

Academic affiliation agreement partners are not business associates.

The Business Associate Addendum describes the permitted uses of the PHI and the business associate’s responsibilities regarding it. If a business associate relationship exists with no written contract, a Business Associate Agreement must be signed.

• (B) Use of Protected Student Financial Information (PSFI) by an Outside Entity

When a person or entity outside UNMC, The Nebraska Medical Center, UDA, and UNMC-P performs a function or activity on behalf of UNMC that involves protected student financial information (PSFI), a Gramm-Leach-Bliley Act (GLBA) Addendum must be added to the contract for GLBA compliance.

The GLBA addendum describes the permitted uses of the PSFI and the service provider’s responsibilities regarding it. If a service provider relationship exists with no written contract, a GLBA agreement must be signed.

• (C) Use of UNMC Information Systems

When a person or entity outside UNMC, The Nebraska Medical Center, UDA and UNMC-P (“service provider”) requires electronic access to UNMC private network resources, and is not a business associate, the service provider shall sign a Business Partner Agreement or Addendum.

Academic Affiliation Agreements. Academic Affiliation agreements are required for all organizations accepting UNMC students and for all students who come to UNMC from other educational institutions for clinical experience. The academic affiliation template shall be used. Any modifications to the academic affiliation template must be approved by the Office of the Vice Chancellor for Academic Affairs. A fully executed original copy of the agreement is kept on file in the Office of the Vice Chancellor for Academic Affairs.

Definitions

Business Associate is defined as a person or entity outside UNMC, The Nebraska Medical Center, University Dental Associates (UDA), and UNMC Physicians (UNMC-P) (the affiliated covered entity) that performs a function or activity on behalf of UNMC that involves the use or disclosure of protected health information (PHI). Health care providers providing treatment are exempt from the business associate requirements.

Independent Contractors are individuals or entities who perform services for or provide goods to UNMC, who are not employees or volunteers. The Internal Revenue Service (IRS) test for independent contractor status depends on three factors: behavioral control, financial control, and relationship of the parties. The general rule is that an individual is an independent contractor if the entity receiving services has the right to control or direct only the result of the work and not the means and methods of accomplishing the work. For more information about independent contractor determination, see IRS Publications 1779 and 15-A.

Protected Health Information (PHI) is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that:

1. is created or received by UNMC; and
2. relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
   

Protected Student Financial Information (PSFI) is information that UNMC has obtained from a student in the process of offering a financial product or service, or such information provided to UNMC by another financial institution. Offering a financial product or service includes offering student loans to students, receiving tax information from a student’s parent when offering a financial aid package and other financial services. Examples of student financial information include addresses, phone numbers, bank and credit account numbers, income and credit histories, and social security numbers in both paper and electronic format.

For additional information, please contact the Compliance Officer or the Director, Business Services, or see [Contracts Policy | Business Associate Agreements and Addendums Procedures].

Contract Signature Authority Table / Independent Contractor Agreement Template Business Partner Agreement or Addendum / Business Associate Agreements and Addendums

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