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Policy No.: '''8009'''<br />
Policy No.: '''8009'''<br />
Effective Date: '''11/01/06'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''DRAFT 12/15/17'''<br />
Revised Date: '''DRAFT 02/22/18'''<br />
Reviewed:<br />  
Reviewed:<br />  
<br />
<br />
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== Basis for Policy ==
== Basis for Policy ==
The purpose of this policy is to provide guidance on who is authorized to sign contracts on behalf of the University of Nebraska Medical Center; and to make clear that individuals must have specific authority, as delegated in Board of Regents Policy [https://www.nebraska.edu/docs/board/RegentPolicies.pdf (RP – 6.3.1)], in [https://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum No. 13] and [https://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf Executive Memorandum No. 14], and as specifically provided for in the UNMC [[Contract Signature Authority]] document, to sign such contracts.
The purpose of this policy is to provide guidance on who is authorized to sign contracts on behalf of the University of Nebraska Medical Center; and to make clear that individuals must have specific authority, as delegated in Board of Regents Policy [https://www.nebraska.edu/docs/board/RegentPolicies.pdf (RP – 6.3.1)], in [https://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum No. 13] and [https://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf Executive Memorandum No. 14], and as specifically provided for in the UNMC [[Contract Signature Authority]] document, to sign such contracts.
==Policy==                                                    
==Policy==  
=== Written Agreements Required ===
=== 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 [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum No. 13] and [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf 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 [mailto:jeffrey.miller@unmc.edu Controller].) No individual shall sign a contract on behalf of the University of Nebraska Medical Center unless specifically identified by the [[Contract Signature Authority]] Table as having the authority to do so.
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 [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum No. 13] and [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf 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 [mailto:wlawlor@unmc.edu Assistant Vice Chancellor for Business and Finance].) No individual shall sign a contract on behalf of the University of Nebraska Medical Center unless specifically identified by the [[Contract Signature Authority]] Table as having the authority to do so.
<br />
===Executive Memorandum No. 14===
<br />
 
Original contracts are maintained as follows:<br />
{| class="wikitable"
{| class="wikitable" width="%"
|-
|valign="center"| Student and Academic Program Affiliations:
!Category!! Authorities
|valign="center"| Vice Chancellor for Academic Affairs Office
|-
| RESEARCH CONTRACTS, meaning federal awards, research grants and contracts and externally funded research related projects|| Sponsored Programs Administration, 402-559-7456, https://www.unmc.edu/spa/contracts/staff.html
|-
| INDUSTRY SPONSORED CLINICAL TRIALS || UNeHealth, 402-559-7614, https://www.unmc.edu/spa/clinical-trials/unehealth/contact.html
|-
| PURCHASES OF GOODS AND SERVICES  || Procurement, [mailto:contracts@unmc.edu contracts@unmc.edu], https://info.unmc.edu/procurement/procurement/contracts/index.html
|-
| LICENSED TECHNOLOGY  || UNeMed, 402-559-3274
|-
|-
|valign="center"| Externally funded projects, including grants, contracts, cooperative<br \> agreements, subcontracts and other subrecipient & vendor agreements:
| BUSINESS FUNCTIONS || Business and Finance 
|valign="center"| Sponsored Programs Administration
When UNMC is expending funds: 402-559-5400, [mailto:contracts@unmc.edu contracts@unmc.edu], https://info.unmc.edu/procurement/procurement/contracts/index.html
 
When UNMC is receiving revenue: 402-559-5200, [mailto:alamer@unmc.edu Amy Lamer] and copy [mailto:wlawlor@unmc.edu William Lawlor]
See [[Contract Signature Authority]]
 
|-
|-
|valign="center"| Continuing Medical Education Program Agreements:
| ACADEMIC AGREEMENTS || Academic Affairs, 402-559-5130, https://www.unmc.edu/academicaffairs/, https://www.unmc.edu/academicaffairs/about/index.html
|valign="center"| Center for Continuing Education
 
|-
|-
|valign="center"| All Others:
| All Others || See [[Contract Signature Authority]] 
|valign="center"| Business Services
|}
|}
===Independent Contractors===
Direct any questions related to the Contract Signature Authority to Sarah Gloden Carlson, [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] at 402-559-9576.
Independent contractors are 3rd parties who perform services for or provide products to UNMC who are neither employees nor volunteers. The [http://info.unmc.edu/procurement/_documents/indep_cont_agreement.doc 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 Sciences, Business Services, or Sponsored Programs Administration (for grants or sponsored programs agreements).
 
====Use of Protected Health Information (PHI) by an Outside Entity====
==Contract Types and Approvals==
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.  
===Research Contracts===
<br />
In compliance with Federal regulations, an individual designated as Institutional Official (IO) is the only authorized signatory authorized to sign on behalf of the institution. Signature by the IO signifies the university agrees to comply with regulations and laws. Sponsored Programs Administration is the authorized signature authority of UNMC for sponsored programs grants and contracts.
<br />
===Industry Sponsored Clinical Trials===
Academic affiliation agreement partners are not business associates.
Contracts associated with funds directly for industry funded clinical trial research are the responsibility of [https://www.unmc.edu/spa/clinical-trials/unehealth/index.html UNeHealth].
<br />
===Purchases of Goods and Services===
Procurement is responsible for contracts where university funds are spent. The Board of Regents Policies and Bylaws provide thresholds that trigger bidding requirements, signature authority and other. Contracts for goods and services utilizing state funding must be reported through a state database under [https://nebraskalegislature.gov/bills/view_bill.php?DocumentID=18635 LB 429] [https://nebraskalegislature.gov/bills/view_bill.php?DocumentID=18635 (Legislative Bill)]. Procurement ensures that information security requirements are met for all [https://info.unmc.edu/procurement/_documents/contracts-quick-reference.pdf purchases].
===Licensed Technology===
[https://www.unemed.com/contact-us/staff-directory UNeMed] focuses on promoting the advancement and commercialization of UNMC technologies. UNeMed signs agreements such as MTAs, CDAs, and Licensing Agreements where rights to UNMC intellectual property are utilized.
===Business Functions===
Agreements involving University stewardship and management of resources are signed by Business and Finance.  
===Academic 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 [mailto:jobshadow@nebraskamed.com (Office of Health Professions Education)]. Academic Affiliation Agreements are approved by the [https://www.unmc.edu/academicaffairs/about/index.html Office of the Vice Chancellor for Academic Affairs]. Contact your college representative responsible for drafting and negotiating Academic Affiliation Agreements or Academic Affairs at 402-559-5130 with questions.
===Data Security/Protected Health Information===
UNMC as part of an [https://www.unmc.edu/hipaa/about/affiliated-covered-entity-structure.pdf Affiliated Covered Entity] is obligated to protect patient information under HIPAA. Any UNMC contract that involves the use of protected health information (PHI) for services, research and other needs to ensure that procedures and policies are followed to secure PHI. <br />
<br />
<br />
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.    
When contracting outside UNMC and Nebraska Medicine for equipment purchases or transfer of PHI electronically, a security review is required by [https://wiki.unmc.edu/index.php/Privacy/Information_Security Information Security].
====Use of Protected Student Financial Information (PSFI) by an Outside Entity====
===Protected Student Financial Information (PSFI)===
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 [http://www.gpo.gov/fdsys/pkg/PLAW-106publ102/pdf/PLAW-106publ102.pdf Gramm-Leach-Bliley Act](GLBA) Addendum must be added to the contract for GLBA compliance. 
[https://www.nebraska.edu/docs/president/26%20Information%20Security%20Plan%20%28GLB%20Compliance%29.pdf Executive Memorandum No. 26] describes protections of Student Financial Information required under Gramm Leach Bliley Act (GLBA), and protection of credit card information received in the course of business. When an activity requires use of protected financial information under Executive Memorandum No. 26, [https://www.nebraska.edu/docs/president/26%20Information%20Security%20Plan%20%28GLB%20Compliance%29.pdf a GLBA Addendum must be added to the contract] (the Addendum is attached as an exhibit to Memorandum 26).
<br />
===Business Associate Agreement===
<br />
A [https://wiki.unmc.edu/index.php/Business_Associate_Agreements_and_Addendums_Procedures Business Associate Agreement] is required in association with the contract for equipment, services or other where a person or entity is performing functions or activities on behalf of a covered entity (UNMC, Nebraska Medicine, College of Dentistry, etc.) or a subcontractor that creates, receives, maintains or transmits PHI on behalf of the covered entity. The [https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template] can be located at https://www.unmc.edu/hipaa/forms/index.html. Refer to the [https://www.unmc.edu/hipaa/forms/docs/wedi-ba-decision-tree-v2.pdf Business Associate Decision Tree] as needed.
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.  
====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.
<br />
<br />
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. The [https://www.unmc.edu/hipaa/forms/docs/unmc-ba-agreement.docx UNMC Business Associate Agreement template] can be located at [https://www.unmc.edu/hipaa/forms/index.html https://www.unmc.edu/hipaa/forms/index.html].
<br \>
<br \>
'''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 [http://www.irs.gov/pub/irs-pdf/p15a.pdf 15-A].
<br \>
<br \>
'''Protected Health Information (PHI)''' is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that:
*is created or received by UNMC; and
*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.
<br />
'''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.
==Additional Information==
==Additional Information==
*For additional information, please contact the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] or the [mailto:wlawlor@unmc.edu Assistant Vice Chancellor for Business and Finance]
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]
*[mailto:wlawlor@unmc.edu Assistant Vice Chancellor for Business and Finance]
*[[Business Associate Agreements and Addendums Procedures]]
*[[Business Associate Agreements and Addendums Procedures]]
*[https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement and Addendums templates]
*[https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template]  
*[https://www.unmc.edu/hipaa/forms/docs/unmc-ba-agreement.docx UNMC Business Associate Agreement template]
*[https://nebraska.edu/docs/board/bylaws.pdf Section 6.4 of the Bylaws of the Board of Regents] of the University of Nebraska Board of Regents Policy on Administrative Approval of University Contracts ([http://www.nebraska.edu/docs/board/RegentPolicies.pdf RP – 6.3.1])
*[https://nebraska.edu/docs/board/bylaws.pdf Section 6.4 of the Bylaws of the Board of Regents] of the University of Nebraska Board of Regents Policy on Administrative Approval of University Contracts ([http://www.nebraska.edu/docs/board/RegentPolicies.pdf RP – 6.3.1])
*University of Nebraska [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum 13], Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions
*University of Nebraska [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum 13], Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions
*University of Nebraska [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf 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 [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf 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 [http://www.nebraska.edu/docs/president/26%20Information%20Security%20Plan%20%28GLB%20Compliance%29.pdf Executive Memorandum No. 26], Information Security Plan   
*University of Nebraska [http://www.nebraska.edu/docs/president/26%20Information%20Security%20Plan%20%28GLB%20Compliance%29.pdf Executive Memorandum No. 26], Information Security Plan   
*University of Nebraska [http://www.nebraska.edu/docs/president/27%20HIPAA%20Compliance.pdf Executive Memorandum No. 27], HIPAA Compliance Plan   
*University of Nebraska [http://www.nebraska.edu/docs/president/27%20HIPAA%20Compliance.pdf Executive Memorandum No. 27], HIPAA Compliance Plan   
*[http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf Health Insurance Portability and Accountability Act of 1996] (HIPAA) [45 CFR §164.502(e)(1)]   
*[http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf Health Insurance Portability and Accountability Act of 1996] (HIPAA) [45 CFR §164.502(e)(1)]   
*[http://www.gpo.gov/fdsys/pkg/PLAW-106publ102/pdf/PLAW-106publ102.pdf Gramm-Leach-Bliley Act](GLBA) 12 CFR §225.28]   
*[http://www.gpo.gov/fdsys/pkg/PLAW-106publ102/pdf/PLAW-106publ102.pdf Gramm-Leach-Bliley Act](GLBA) 12 CFR §225.28]   
*[[Contract Signature Authority]] Table
*[[Contract Signature Authority]] Table
*IRS Publication [http://www.irs.gov/pub/irs-pdf/p15a.pdf 15-A]
*IRS Publication [http://www.irs.gov/pub/irs-pdf/p15a.pdf 15-A]
*[http://info.unmc.edu/procurement/_documents/indep_cont_agreement.doc Independent Contractor Agreement Template]


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