HomeMy WebLinkAboutResolution - 2016-R0034 - Data Usage Agreement With DSHS - 01/28/2016Resolution No. 2016-R0034
Item No. 5.13
January 28, 2016
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to
execute for and on behalf of the City of Lubbock a Data Usage Agreement (DUA) with
the State of Texas' Department of State Health Services (DSHS), providing for use of
confidential state data and related security protocols, in connection with the following
local service agreements previously entered into between the City of Lubbock and the
State of Texas:
No. 2016-004025-00 — Public Health Emergency Preparedness;
No. 2016-003831-00 — IDCU/SUREB Infectious Disease Control
Unit/Surveillance and Epidemiology Ebola Activities;
No. 2016-001290-00 — IMM/LOCALS Immunization Branch -Locals;
No. 2016-001286-00 — RLSS/LPHS RLSS/Local Public Health System-PnP;
and
No. 537-16-0020-00001 — Texas Electronic Registration Remote System (TER
Remote System)
The Data Usage Agreement is attached hereto and incorporated in this Resolution as if
fully set forth herein and shall be included in the minutes of the Council.
Passed by the City Council this January 28, 2016.
GtPrO.'ROISERTSON, MAYOR
ATTEST:
Rebe ca Garza, City Secret
az
APPROVED AS TO CONTENT:
Katherine Wells, MPH
Director of Public Health
(With regard to Contracts
2016-004025-00;2016-003831-00;
2016-001290-00; and 2016-001286-00)
APPROVED AS TO CONTENT:
Reb cca Garza, City Secret
ar
(With regard to Contract
537-16-0020-00001)
Resolution No. 2016-R0034
DATA USE AGREEMENT
BETWEEN THE
TEXAS HEALTH AND HUMAN SERVICES ENTERPRISE
AND
CITY OF LUBBOCK ("CONTRACTOR")
This Data Use Agreement ("DUA"), effective as of the Base Contract ("Effective Date"), is entered
into by and between the Texas Health and Human Services Enterprise agency DEPARTMENT OF STATE
HEALTH SERVICES ("HHS") and CITY OF LUBBOCK ("CONTRACTOR"), and incorporated into the
terms of the following Base Contracts, in Travis County, Texas:
2016-004025-00 — Public Health Emergency Preparedness
2016-003831-00 — IDCU/SUREB Infectious Disease Control Unit/Surveillance and
Epidemiology Ebola Activities
2016-001290-00 — IMM/LOCALS Immunization Branch -Locals
2016-001286-00 — RLSS/LPHS RLSS/Local Public Health System-PnP
537-16-0020-00001— Texas Electronic Registration Remote System (TER Remote System)
ARTICLE I. PURPOSE; APPLICABILITY; ORDER OF PRECEDENCE
The purpose of this DUA is to facilitate creation, receipt, maintenance, use, disclosure or access to
Confidential Information with CONTRACTOR, and describe CONTRACTOR's rights and obligations with
respect to the Confidential Information and the limited purposes for which the CONTRACTOR may create,
receive, maintain, use, disclose or have access to Confidential Information. 45 CFR 164.504(e)(1)-(3) This
DUA also describes HHS's remedies in the event of CONTRACTOR's noncompliance with its obligations
under this DUA. This DUA applies to both Business Associates and contractors who are not Business
Associates who create, receive, maintain, use, disclose or have access to Confidential Information on behalf of
HHS, its programs or clients as described in the Base Contract.
As of the Effective Date of this DUA, if any provision of the Base Contract, including any General
Provisions or Uniform Terms and Conditions, conflicts with this DUA, this DUA controls. This DUA is
intended to apply only to Confidential Information that CONTRACTOR handles in performing services
provided under the Base Contract.
ARTICLE 2. DEFINITIONS
For the purposes of this DUA, capitalized, underlined terms have the meanings set forth in the
following: Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (42 U.S.C.
§ 1320d, etseq.) and regulations thereunder in 45 CFR Parts 160 and 164, including all amendments, regulations
and guidance issued thereafter; The Social Security Act, including Section 1137 (42 U.S.C. §§ 1320b-7), Title
XVI of the Act; The Privacy Act of 1974, as amended by the Computer Matching and Privacy Protection Act
of 1988, 5 U.S.C. § 552a and regulations and guidance thereunder; Internal Revenue Code, Title 26 of the
United States Code and regulations and publications adopted under that code, including IRS Publication 1075;
OMB Memorandum 07-18; Texas Business and Commerce Code Ch. 521; Texas Government Code, Ch. 552,
and Texas Government Code §2054.1125. In addition, the following terms in this DUA are defined as follows:
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
GOVERNMENTAL ENTITY VERSION -CITY OF LUBBOCK
HHS Comnacl No. 2014-044190-001
"Authorized Purpose" means the specific purpose or purposes described in the Scope of Work of
the Base Contract for CONTRACTOR to fulfill its obligations under the Base Contract, or any other purpose
expressly authorized by HHS in writing in advance.
"Authorized User" means a Person:
(1) Who is authorized to create, receive, maintain, have access to, process, view, handle,
examine, interpret, or analyze Confidential Information pursuant to this DUA;
(2) For whom CONTRACTOR warrants and represents has a demonstrable need to create,
receive, maintain, use, disclose or have access to the Confidential Information; and
(3) Who has agreed in writing to be bound by the disclosure and use limitations pertaining to
the Confidential Information as required by this DUA.
"Confidential Information" means any communication or record (whether oral, written,
electronically stored or transmitted, or in any other form) provided to or made available to CONTRACTOR or
that CONTRACTOR may create, receive, maintain, use, disclose or have access to on behalf of HHS that
consists of or includes any or all of the following:
(1) Client Information;
(2) Protected Health Information in any form including without limitation, Electronic
Protected Health Information or Unsecured Protected Health Information,
(3) Sensitive Personal Information defined by Texas Business and Commerce Code Ch. 521;
(4) Federal Tax Information;
(5) Personally Identifiable Information;
(6) Social Security Administration Data, including, without limitation, Medicaid information;
(7) All privileged work product;
(8) All information designated as confidential under the constitution and laws of the State of
Texas and of the United States, including the Texas Health & Safety Code and the Texas Public Information
Act, Texas Government Code, Chapter 552.
"Leeally Authorized Representative" of the Individual, as defined by Texas law, including as
provided in 45 CFR 435.923 (Medicaid); 45 CFR 164.502(8)(1) (HIPAA); Tex. Occ. Code § 151.002(6); Tex.
H. & S. Code § 166.164; Estates Code Ch. 752 and Texas Prob. Code § 3.
ARTICLE 3.CONTRACTOR'S DUTIES REGARDING CONFIDENTIAL INFORMATION
Section 3.01 Obligations ofCONTRACTOR
CONTRACTOR agrees that:
(A) CONTRACTOR will exercise reasonable care and no less than the same degree of care
CONTRACTOR uses to protect its own confidential, proprietary and trade secret information to prevent
any portion of the Confidential Information from being used in a manner that is not expressly an Authorized
Purpose under this DUA or as Required by Law. 45 CFR 164.502(b)(1); 45 CFR 164.514(d)
(B) CONTRACTOR will not, without HHS's prior written consent, disclose or allow access to
any portion of the Confidential Information to any Person or other entity, other than Authorized User's
Workforce or Subcontractors of CONTRACTOR who have completed training in confidentiality, privacy,
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 2 of 13
III IS Contract No. 2014-044190-001
security and the importance of promptly reporting any Event or Breach to CONTRACTOR's management,
to carry out the Authorized Purpose or as Ree uired by Law.
HHS, at its election, may assist CONTRACTOR in training and education on specific or unique
HHS processes, systems and/or requirements. CONTRACTOR will produce evidence of completed
training to HHS upon request. 45 C.F.R. 164.308(a)(5)(i); Texas Health & Safety Code §181.101
(C) CONTRACTOR will establish, implement and maintain appropriate sanctions against any
member of its Workforce or Subcontractor who fails to comply with this DUA, the Base Contract or
applicable law. CONTRACTOR will maintain evidence of sanctions and produce it to HHS upon request.45
C.F.R. 164.308(a)(1)(ii)(C); 164.530(e); 164.410(h); 164.530(6)(1)
(D) CONTRACTOR will not, except as otherwise permitted by this DUA, disclose or provide
access to any Confidential Information on the basis that such act is Required by Law without notifying
either HHS or CONTRACTOR's own legal counsel to determine whether CONTRACTOR should object
to the disclosure or access and seek appropriate relief. CONTRACTOR will maintain an accounting of all
such requests for disclosure and responses and provide such accounting to HHS within 48 hours of HHS'
request. 45 CFR 164.504(e)(2)(ii)(A)
(E) CONTRACTOR will not attempt to re -identify or further identify Confidential Information
or De -identified Information, or attempt to contact any Individuals whose records are contained in the
Confidential Information. except for an Authorized Purpose, without express written authorization from
HHS or as expressly permitted by the Base Contract. 45 CFR 164.502(d)(2)(i) and (ii) CONTRACTOR
will not engage in prohibited marketing or sale of Confidential Information. 45 CFR 164.501,
164.508(a)(3) and (4); Texas Health & Safety Code Ch. 181.002
(F) CONTRACTOR will not permit, or enter into any agreement with a Subcontractor to,
create, receive, maintain, use, disclose, have access to or transmit Confidential Information, on behalf of
CONTRACTOR without requiring that Subcontractor first execute the Form Subcontractor Agreement,
Attachment 1, which ensures that the Subcontractor will comply with the identical terms, conditions,
safeguards and restrictions as contained in this DUA for PHI and any other relevant Confidential
Information and which permits more strict limitations; and 45 CFR 164.502(e)(1)(1)(ii); 164.504(e)(1)(i)
and (2)
(G) CONTRACTOR is directly responsible for compliance with, and enforcement of, all
conditions for creation, maintenance, use, disclosure, transmission and Destruction of Confidential Information
and the acts or omissions of Subcontractors as may be reasonably necessary to prevent unauthorized use. 45
CFR 164.504(e)(5); 42 CFR 431.300, et seq.
(H) If CONTRACTOR maintains PHI in a Designated Record Set, CONTRACTOR will make
PHI available to HHS in a Designated Record Set or, as directed by HHS, provide PHI to the Individual,
or Legally Authorized Representative of the Individual who is requesting PHI in compliance with the
requirements of the HIPAA Privacy Regulations. CONTRACTOR will make other Confidential
Information in CONTRACTOR's possession available pursuant to the requirements of HIPAA or other
applicable law upon a determination of a Breach of Unsecured PHI as defined in HIPAA. 45 CFR
164.524and 164.504(e)(2)(ii)(E)
(I) CONTRACTOR will make PHI as required by HIPAA available to HHS for amendment
and incorporate any amendments to this information that HHS directs or agrees to pursuant to the HIPAA.
45 CFR 164.504(e)(2)(ii)(E) and (F)
(J) CONTRACTOR will document and make available to HHS the PHI required to provide
access, an accounting of disclosures or amendment in compliance with the requirements of the HIPAA
Privacy Regulations. 45 CFR 164.504(e)(2)(ii)(C) and 164.528
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 3 of 13
HHS Contract No. 2014-044190-001
(K) If CONTRACTOR receives a request for access, amendment or accounting of PHI from
an individual with a right of access to information subject to this DUA, it will respond to such request in
compliance with the HIPAA Privacy Regulations. CONTRACTOR will maintain an accounting of all
responses to requests for access to or amendment of PHI and provide it to HHS within 48 hours of HHS'
request. 45 CFR 164.504(e)(2).
(L) CONTRACTOR will provide, and will cause its Subcontractors and agents to provide, to
HHS periodic written certifications of compliance with controls and provisions relating to information
privacy, security and breach notification, including without limitation information related to data transfers
and the handling and disposal of Confidential Information. 45 CFR 164.308; 164.530(c); 1 TAC 202
(M) Except as otherwise limited by this DUA, the Base Contract, or law applicable to the
Confidential Information, CONTRACTOR may use or disclose PHI for the proper management and
administration of CONTRACTOR or to carry out CONTRACTOR's legal responsibilities if: 45 CFR
164.504(e) (1 i) (1) (A)
3.01(D); (1) Disclosure is Required by Law, provided that CONTRACTOR complies with Section
(2) CONTRACTOR obtains reasonable assurances from the Person to whom the information
is disclosed that the Person will:
(a) Maintain the confidentiality of the Confidential Information in accordance with this DUA;
(b) Use or further disclose the information only as Required by Law or for the Authorized Purpose
for which it was disclosed to the Person; and
(c) Notify CONTRACTOR in accordance with Section 4.01 of any Event or Breach of Confidential
Information of which the Person discovers or should have discovered with the exercise of
reasonable diligence. 45 CFR 164.504(e)(4)(11)(B)
(N) Except as otherwise limited by this DUA, CONTRACTOR will, if requested by HHS, use
PHI to provide data aggregation services to HHS, as that term is defined in the HIPAA, 45 C.F.R. § 164.501
and permitted by HIPAA. 45 CFR 164.504(e)(2)(1)(B)
(0) CONTRACTOR will, on the termination or expiration of this DUA or the Base Contract,
at its expense, return to HHS or Destroy, at HHS's election, and to the extent reasonably feasible and
permissible by law, all Confidential Information received from HHS or created or maintained by
CONTRACTOR or any of CONTRACTOR's agents or Subcontractors on HHS's behalf if that data
contains Confidential Information. CONTRACTOR will certify in writing to HHS that all the Confidential
Information that has been created, received, maintained, used by or disclosed to CONTRACTOR, has been
Destroyed or returned to HHS, and that CONTRACTOR and its agents and Subcontractors have retained
no copies thereof. Notwithstanding the foregoing, CONTRACTOR acknowledges and agrees that it may
not Destroy any Confidential Information if federal or state law, or HHS record retention policy or a
litigation hold notice prohibits such Destruction. If such return or Destruction is not reasonably feasible,
or is impermissible by law, CONTRACTOR will immediately notify HHS of the reasons such return or
Destruction is not feasible, and agree to extend indefinitely the protections of this DUA to the Confidential
Information and limit its further uses and disclosures to the purposes that make the return of the Confidential
Information not feasible for as long as CONTRACTOR maintains such Confidential Information, 45 CFR
164.504(e) (2) (Y) ()
(P) CONTRACTOR will create, maintain, use, disclose, transmit or Destroy Confidential
Information in a secure fashion that protects against any reasonably anticipated threats or hazards to the
security or integrity of such information or unauthorized uses. 45 CFR 164.306, 164.530(c)
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 4 of 13
I II IS Contract No. 2014-044190-001
(Q) If CONTRACTOR accesses, transmits, stores, and/or maintains Confidential Information,
CONTRACTOR will complete and return to HHS at infosecurity@hhsc.state.tx.us the HHS information
security and privacy initial inquiry (SPI) at Attachment 2 . The SPI identifies basic privacy and security
controls with which CONTRACTOR must comply to protect HHS Confidential Information.
CONTRACTOR will comply with periodic security controls compliance assessment and monitoring by
HHS as required by state and federal law, based on the type of Confidential Information CONTRACTOR
creates, receives, maintains, uses, discloses or has access to and the Authorized Purpose and level of risk.
CONTRACTOR's security controls will be based on the National Institute of Standards and Technology
(NIST) Special Publication 800-53. CONTRACTOR will update its security controls assessment whenever
there are significant changes in security controls for HHS Confidential Information and will provide the
updated document to HHS. HHS also reserves the right to request updates as needed to satisfy state and
federal monitoring requirements. 45 CFR 164.306
(R) CONTRACTOR will establish, implement and maintain any and all appropriate
procedural, administrative, physical and technical safeguards to preserve and maintain the confidentiality,
integrity, and availability of the Confidential Information, and with respect to PHI, as described in the
HIPAA Privacy and Security Regulations, or other applicable laws or regulations relating to Confidential
Information, to prevent any unauthorized use or disclosure of Confidential Information as long as
CONTRACTOR has such Confidential Information in its actual or constructive possession. 45 CFR
164.308 (administrative safeguards); 164.310 (physical safeguards); 164.312 (technical safeguards);
164.530(c)(privacy safeguards)
(S) CONTRACTOR will designate and identify, subject to HHS approval, a Person or Persons,
as Privacy Official 45 CFR 164.530(a)(1) and Information Security Official, each of whom is authorized
to act on behalf of CONTRACTOR and is responsible for the development and implementation of the
privacy and security requirements in this DUA. CONTRACTOR will provide name and current address,
phone number and e-mail address for such designated officials to HHS upon execution of this DUA and
prior to any change. 45 CFR 164.308(a)(2)
(T) CONTRACTOR represents and warrants that its Authorized Users each have a
demonstrated need to know and have access to Confidential Information solely to the minimum extent
necessary to accomplish the Authorized Purpose pursuant to this DUA and the Base Contract, and further,
that each has agreed in writing to be bound by the disclosure and use limitations pertaining to the
Confidential Information contained in this DUA. 45 CFR 164.502, 164.514(d)
(U) CONTRACTOR and its Subcontractors will maintain an updated, complete, accurate and
numbered list of Authorized Users, their signatures, titles and the date they agreed to be bound by the terms
of this DUA, at all times and supply it to HHS, as directed, upon request.
(V) CONTRACTOR will implement, update as necessary, and document reasonable and
appropriate policies and procedures for privacy, security and Breach of Confidential Information and an
incident response plan for an Event or Breach, to comply with the privacy, security and breach notice
requirements of this DUA prior to conducting work under the DUA. 45 CFR 164.308; 164.316, 164.514(d);
164.530(1)(1)
(W) CONTRACTOR will produce copies of its information security and privacy policies and
procedures and records relating to the use or disclosure of Confidential Information received from, created
by, or received, used or disclosed by CONTRACTOR on behalf of HHS for HHS's review and approval
within 30 days of execution of this DUA and upon request by HHS the following business day or other
agreed upon time frame. 45 CFR 164.308, 164.514(d)
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 5 of 13
I IIIS Contract No. 2014-044190-001
(X) CONTRACTOR will make available to HHS any information HHS requires to fulfill HHS's
obligations to provide access to, or copies of, PHI in accordance with HIPAA and other applicable laws and
regulations relating to Confidential Information. CONTRACTOR will provide such information in a time and
manner reasonably agreed upon or as designated by the Secretary, or other federal or state law. 45 CFR
164.504(e)(2)(i)(1)
(Y) CONTRACTOR will only conduct secure transmissions of Confidential Information
whether in paper, oral or electronic form. A secure transmission of electronic Confidential Information in
motion includes secure File Transfer Protocol (SFTP) or Encryption at an appropriate level or otherwise
protected as required by rule, regulatiop or law. HHS Confidential Information at rest requires Encryption
unless there is adequate administrative, technical, and physical security, or as otherwise protected as
required by rule, regulation or law. All electronic data transfer and communications of Confidential
Information will be through secure systems. Proof of system, media or device security and/or Encryption
must be produced to HHS no later than 48 hours after HHS's written request in response to a compliance
investigation, audit or the Discovery of an Event or Breach. Otherwise, requested production of such proof
will be made as agreed upon by the parties. De -identification of HHS Confidential Information is a means
of security. With respect to de -identification of PHI, "secure" means de -identified according to HIPAA
Privacy standards and regulatory guidance. 45 CFR 164.312; 164.530(d)
(Z) CONTRACTOR will comply with the following laws and standards if applicable to the type of
Confidential Information and Contractor's Authorized Purpose:
• Title 1, Part 10, Chapter 202, Subchapter B, Texas Administrative Code;
• The Privacy Act of 1974;
• OMB Memorandum 07-16;
• The Federal Information Security Management Act of 2002 (FISMA);
• The Health Insurance Portability and Accountability Act of 1996(HIPAA) as defined in the
DUA;
• Internal Revenue Publication 1075 — Tax Information Security Guidelines for Federal, State
and Local Agencies;
• National Institute of Standards and Technology (NIST) Special Publication 800-66 Revision 1
— An Introductory Resource Guide for Implementing the Health Insurance Portability and
Accountability Act (HIPAA) Security Rule;
• NIST Special Publications 800-53 and 800-53A — Recommended Security Controls for Federal
Information Systems and Organizations, as currently revised;
• NIST Special Publication 800-47 — Security Guide for Interconnecting Information
Technology Systems;
• NIST Special Publication 800-88, Guidelines for Media Sanitization;
• NIST Special Publication 800-111, Guide to Storage of Encryption Technologies for End User
Devices containing PHI; and
• Any other State or Federal law, regulation, or administrative rule relating to the specific HHS
program area that CONTRACTOR supports on behalf of HHS.
ARTICLE 4. BREACH NOTICE, REPORTING AND CORRECTION REQUIREMENTS
Section 4.01. Breach or Event Notification to HHS. 45 CFR 164.400-414
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April I, 2015
Page 6 of 13
I IHS Contract No. 2014-044190-001
(A) CONTRACTOR will cooperate fully with HHS in investigating, mitigating to the extent
practicable and issuing notifications directed by HHS, for any Event or Breach of Confidential Information
to the extent and in the manner determined by HHS.
(B) CONTRACTOR'S obligation begins at the Discovery of an Event or Breach and continues
as long as related activity continues, until all effects of the Event are mitigated to HHS's satisfaction (the
"incident response period"). 45 CFR 164.404
(C) Breach Notice:
1. Initial Notice.
a. For federal information, including without limitation, Federal Tax Information, Social Security
Administration Data and Medicaid Client Information, within the first, consecutive clock hour of
Discovery, and for all other types of Confidential Information not more than 24 hours after Discovery, or
in a timeframe otherwise approved by HHS in writing, initially report to HHS's Privacy and Security
Officers via email at: privacy@HHSC.state.tx.us and to the HHS division responsible for this DUA• and
IRS Publication 1075; Privacy Act of 1974, as amended by the Computer Matching and Privacy
Protection Act of 1988, 5 U.S.C. § 552a; OMB Memorandum 07-16 as cited in HHSC-CMS Contracts
for information exchange.
b. Report all information reasonably available to CONTRACTOR about the Event or Breach of the
privacy or security of Confidential Information. 45 CFR 164.410
c. Name, and provide contact information to HHS for, CONTRACTOR's single point of contact
who will communicate with HHS both on and off business hours during the incident response period.
2. 48 -Hour Formal Notice. No later than 48 consecutive clock hours after Discovery, or a
time within which Discovery reasonably should have been made by CONTRACTOR of an Event or Breach
of Confidential Information, provide formal notification to the State, including all reasonably available
information about the Event or Breach, and CONTRACTOR's investigation, including without limitation
and to the extent available: For (a) - (m) below: 45 CFR 164.400-414
a. The date the Event or Breach occurred;
b. The date of CONTRACTOR's and, if applicable, Subcontractor's Discoverv;
c. A brief description of the Event or Breach: including how it occurred and who is responsible (or
hypotheses, if not yet determined);
d. A brief description of CONTRACTOR's investigation and the status of the investigation;
e. A description of the types and amount of Confidential Information involved;
f. Identification of and number of all Individuals reasonably believed to be affected, including first
and last name of the individual and if applicable the, Legally authorized representative, last known address,
age, telephone number, and email address if it is a preferred contact method, to the extent known or can be
reasonably determined by CONTRACTOR at that time;
g. CONTRACTOR's initial risk assessment of the Event or Breach demonstrating whether
individual or other notices are required by applicable law or this DUA for HHS approval, including an
analysis of whether there is a low probability of compromise of the Confidential Information or whether
any legal exceptions to notification apply;
It. CONTRACTOR's recommendation for HHS's approval as to the steps Individuals and/or
CONTRACTOR on behalf of Individuals, should take to protect the Individuals from potential harm,
including without limitation CONTRACTOR's provision of notifications, credit protection, claims
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 7 of 13
HHS Contact No. 2014-044190-001
monitoring, and any specific protections for a Legally Authorized Representative to take on behalf of an
Individual with special capacity or circumstances;
i. The steps CONTRACTOR has taken to mitigate the harm or potential harm caused (including
without limitation the provision of sufficient resources to mitigate);
j. The steps CONTRACTOR has taken, or will take, to prevent or reduce the likelihood of
recurrence of a similar Event or Breach;
k. Identify, describe or estimate of the Persons, Workforce, Subcontractor, or Individuals and any
law enforcement that may be involved in the Event or Breach;
1. A reasonable schedule for CONTRACTOR to provide regular updates to the foregoing in the
future for response to the Event or Breach, but no less than every three (3) business days or as otherwise
directed by HHS, including information about risk estimations, reporting, notification, if any, mitigation,
corrective action, root cause analysis and when such activities are expected to be completed; and
in. Any reasonably available, pertinent information, documents or reports related to an Event or
Breach that HHS requests following Discovery.
Section 4.02 Investigation, Response and Mitigation. ForA-F below: 45 CFR 164.308, 310 and 312;
164.530
(A) CONTRACTOR will immediately conduct a full and complete investigation, respond to
the Event or Breach commit necessary and appropriate staff and resources to expeditiously respond, and
report as required to and by HHS for incident response purposes and for purposes of HHS's compliance
with report and notification requirements, to the satisfaction of HHS.
(B) CONTRACTOR will complete or participate in a risk assessment as directed by HHS
following an Event or Breach, and provide the final assessment, corrective actions and mitigations to HHS
for review and approval.
(C) CONTRACTOR will fully cooperate with HHS to respond to inquiries and/or proceedings
by state and federal authorities, Persons and/or Individuals about the Event or Breach.
(D) CONTRACTOR will fully cooperate with HHS's efforts to seek appropriate injunctive
relief or otherwise prevent or curtail such Event or Breach, or to recover or protect any Confidential
Informationincluding complying with reasonable corrective action or measures, as specified by HHS in
a Corrective Action Plan if directed by HHS under the Base Contract.
Section 4.03 Breach Notification to Individuals and Reporting to Authorides. Tex Bus. & Comm.
Code §521.053; 45 CFR 164.404 (Individuals), 164.406 (Media); 164.408 (Authorities)
(A) HHS may direct CONTRACTOR to provide Breach notification to Individuals regulators
or third -parties, as specified by HHS following a Breach.
(B) CONTRACTOR must obtain HHS's prior written approval of the time, manner and content
of any notification to Individuals, regulators or third -parties, or any notice required by other state or federal
authorities. Notice letters will be in CONTRACTOR's name and on CONTRACTOR's letterhead, unless
otherwise directed by HHS, and will contain contact information, including the name and title of
CONTRACTOR's representative, an email address and a toll-free telephone number, for the Individual to
obtain additional information.
(C) CONTRACTOR will provide HHS with copies of distributed and approved
communications.
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 8 of 13
IIIIS Conti -act No. 2014-044190-001
(D) CONTRACTOR will have the burden of demonstrating to the satisfaction of HHS that any
notification required by HHS was timely made. If there are delays outside of CONTRACTOR's control,
CONTRACTOR will provide written documentation of the reasons for the delay.
(E) If HHS delegates notice requirements to CONTRACTOR, HHS shall, in the time and manner
reasonably requested by CONTRACTOR, cooperate and assist with CONTRACTOR's information
requests in order to make such notifications and reports.
ARTICLE 5. SCOPE OF WORK
Scope of Work means the services and deliverables to be performed or provided by CONTRACTOR,
or on behalf of CONTRACTOR by its Subcontractors or agents for HHS that are described in detail in the Base
Contract. The Scope of Work including any future amendments thereto, is incorporated by reference in this
DUA as if set out word-for-word herein.
ARTICLE 6. GENERAL PROVISIONS
Section 6.01 Ownership of Confidential Information
CONTRACTOR acknowledges and agrees that the Confidential Information is and will remain the
property of HHS. CONTRACTOR agrees it acquires no title or rights to the Confidential Information.
Section 6.02 HHS Commitment and Obligations
HHS will not request CONTRACTOR to create, maintain, transmit, use or disclose PHI in any manner that
would not be permissible under applicable law if done by HHS.
Section 6.03 HHS Right to Inspection
At any time upon reasonable notice to CONTRACTOR, or if HHS determines that CONTRACTOR
has violated this DUA, HHS, directly or through its agent, will have the right to inspect the facilities, systems,
books and records of CONTRACTOR to monitor compliance with this DUA. For purposes of this subsection,
HHS's agent(s) include, without limitation, the HHS Office of the Inspector General or the Office of the
Attorney General of Texas, outside consultants or legal counsel or other designee.
Section 6.04 Term; Termination of DUA; Survival
This DUA will be effective on the date on which CONTRACTOR executes the DUA, and will
terminate upon termination of the Base Contract and as set forth herein . If the Base Contract is extended or
amended, this DUA is updated automatically concurrent with such extension or amendment.
(A) HHS may immediately terminate this DUA and Base Contract upon a material violation of
this DUA.
(B) Termination or Expiration of this DUA will not relieve CONTRACTOR of its obligation
to return or Destroy the Confidential Information as set forth in this DUA and to continue to safeguard the
Confidential Information until such time as determined by HHS.
(D) If HHS determines that CONTRACTOR has violated a material term of this DUA; HHS
may in its sole discretion:
I. Exercise any of its rights including but not limited to reports, access and inspection under
this DUA and/or the Base Contract; or
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 9 of 13
11115 Contract No. 2014-044190-001
2. Require CONTRACTOR to submit to a corrective action plan, including a plan for
monitoring and plan for reporting, as HHS may determine necessary to maintain compliance with
this DUA; or
3. Provide CONTRACTOR with a reasonable period to cure the violation as determined by
HHS; or
4. Terminate the DUA and Base Contract immediately, and seek relief in a court of competent
jurisdiction in Travis County, Texas.
Before exercising any of these options, HHS will provide written notice to CONTRACTOR
describing the violation and the action it intends to take.
(E) If neither termination nor cure is feasible, HHS shall report the violation to the Secretary.
(F) The duties of CONTRACTOR or its Subcontractor under this DUA survive the expiration or
termination of this DUA until all the Confidential Information is Destroyed or returned to HHS, as required
by this DUA.
Section 6.05 Governing Law, Venue and Litigation
(A) The validity, construction and performance of this DUA and the legal relations among the
Parties to this DUA will be governed by and construed in accordance with the laws of the State of Texas.
(B) The Parties agree that the courts of Travis County, Texas, will be the exclusive venue for
any litigation, special proceeding or other proceeding as between the parties that may be brought, or arise
out of, or in connection with, or by reason of this DUA.
Section 6.06 Injunctive Relief
(A) CONTRACTOR acknowledges and agrees that HHS may suffer irreparable injury if
CONTRACTOR or its Subcontractor fails to comply with any of the terms of this DUA with respect to the
Confidential Information or a provision of HIPAA or other laws or regulations applicable to Confidential
Information.
(B) CONTRACTOR further agrees that monetary damages may be inadequate to compensate
HHS for CONTRACTOR's or its Subcontractor's failure to comply. Accordingly, CONTRACTOR agrees
that HHS will, in addition to any other remedies available to it at law or in equity, be entitled to seek
injunctive relief without posting a bond and without the necessity of demonstrating actual damages, to
enforce the terms of this DUA.
Section 6.07 Indemnifrcation
This section has intentionally been deleted.
Section 6.08 Insurance
(A) CONTRACTOR represents and warrants that it maintains either self-insurance or
commercial insurancewith policy limits sufficient to cover any liability arising from any acts or omissions
by CONTRACTOR or its employees, directors, officers, Subcontractors, or agents or other members of its
Workforce under this DUA. CONTRACTOR warrants that HHS will be a loss payee and beneficiary for any
such claims. .
(B) CONTRACTOR will provide HHS with written proof that required insurance coverage is in
effect, at the request of HHS.
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 10 of 13
I IFi'� Contract No. 2014-044190-001
Section 6.09 Fees and Costs
Except as otherwise specified in this DUA or the Base Contract, including but not limited to
requirements to insure and/or indemnify HHS, if any legal action or other proceeding is brought for the
enforcement of this DUA, or because of an alleged dispute, contract violation, Event, Breach, default,
misrepresentation, or injunctive action, in connection with any of the provisions of this DUA, each party will
bear their own legal expenses and the other cost incurred in that action or proceeding.
Section 6.10 Entirety of the Contract
This Data Use Agreement is incorporated by reference into the Base Contract and, together with the
Base Contract, constitutes the entire agreement between the parties. No change, waiver, or discharge of
obligations arising under those documents will be valid unless in writing and executed by the party against
whom such change, waiver, or discharge is sought to be enforced.
Section 6.11 Automatic Amendment and Interpretation
Upon the effective date of any amendment or issuance of additional regulations to HIPAA, or any
other law applicable to Confidential Information, this DUA will automatically be amended so that the
obligations imposed on HHS and/or CONTRACTOR remain in compliance with such requirements. Any
ambiguity in this DUA will be resolved in favor of a meaning that permits HHS and CONTRACTOR to comply
with HIPAA or any other law applicable to Confidential Information.
ARTICLE 7. AUTHORITY To EXECUTE
The Parties have executed this DUA in thew capacities as stated below with authority to bind their
organizations on the dates set forth by their signatures.
IN WITNESS HEREOF, HHS and CONTRACTOR have each caused this DUA to be signed and
delivered by its duly authorized representative:
TEXAS HEALTH AND HUMAN SERVICES
BY: _
NAME:
TITLE:
DATE:
CONTRACTOR /
By:
Gle . Robertson, Mayor
ATTEST:
By:
Rebe ca Garza, City Secreta,
APPE AS TO
By:
atherine Wells, MPH
Director of Public Health
(With regard to Base Contracts
2016-004025-00;2016-003831-00;
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April I, 2015
Page I I of 13
11115 Conti -act No. 2014-044190-001
2016-001290-00; and 2016-001286-00)
APPROVED AS TO CONT 'VT:
By:
Rebec a Garza, City Secre ry
(With egard to Base Contr
537-16-0020-00001.)
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April I, 2015
Page 12 of 13
IilIS Contract \x.2014-044190-001
ATTACHMENT 1. SUBCONTRACTOR AGREEMENT FORM
HHS CONTRACT NUMBER 2014-044190-001
The DUA between HHS and CONTRACTOR establishes the permitted and required uses and disclosures
of Confidential Information by CONTRACTOR.
CONTRACTOR has subcontracted with
(SUBCONTRACTOR) for performance of duties on behalf of CONTRACTOR which are subject to the
DUA. SUBCONTRACTOR acknowledges, understands and agrees to be bound by the identical terms
and conditions applicable to CONTRACTOR under the DUA, incorporated by reference in this
Agreement, with respect to HHS Confidential Information. CONTRACTOR and SUBCONTRACTOR
agree that HHS is a third -parry beneficiary to applicable provisions of the subcontract.
HHS has the right but not the obligation to review or approve the terms and conditions of the subcontract
by virtue of this Subcontractor Agreement Form.
CONTRACTOR and SUBCONTRACTOR assure HHS that any Breach or Event as defined by the DUA
that SUBCONTRACTOR Discovers will be reported to HHS by CONTRACTOR in the time, manner
and content required by the DUA.
If CONTRACTOR knows or should have known in the exercise of reasonable diligence of a pattern of
activity or practice by SUBCONTRACTOR that constitutes a material breach or violation of the DUA or
the SUBCONTRACTOR's obligations CONTRACTOR will:
1. Take reasonable steps to cure the violation or end the violation, as applicable;
2. If the steps are unsuccessful, terminate the contract or arrangement with SUBCONTRACTOR, if
feasible;
3. Notify HHS immediately upon reasonably discovery of the pattern of activity or practice of
SUBCONTRACTOR that constitutes a material breach or violation of the DUA and keep HHS
reasonably and regularly informed about steps CONTRACTOR is taking to cure or end the
violation or terminate SUBCONTACTOR's contract or arrangement.
This Subcontractor Agreement Form is executed by the parties in their capacities indicated below.
CONTRACTOR
BY:
BY:
NAME:
NAME
TITLE:
TITLE
DATE
,201. DATE
SUBCONTRACTOR
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1, 2015
Page 13 of 13