REGISTER FOR HIPAA COMPLIANCE PROGRAM

Please fill out and submit forms below online or you may open and download the PDF version, fill out the forms and return by email to info@keybenefits.com.  We will then contact you with more information and a proposal, which includes pricing based on your unique needs.

Online Version

KEY BENEFIT CONCEPTS, LLC
HIPAA PRIVACY AND SECURITY AND BREACH RULES
FOR HEALTH CARE PLANS

COPYRIGHT OWNERSHIP AND STATEMENT OF ALLOWED USE

The undersigned acknowledges receiving services, data and forms from Key Benefit Concepts, LLC relating to HIPAA Privacy and Security for Health Care Plans, including guidelines relating to the Breach Rules. Such services and information were prepared by Key Benefit Concepts, LLC.

The undersigned further acknowledges that such materials and forms are subject to Copyright protection by the laws of the United States and are the exclusive property of Michael Best & Friedrich LLP, Quarles & Brady LLP and/or Key Benefit Concepts, LLC.

Key Benefit Concepts, LLC has purchased HIPAA manuals and forms from Michael Best & Friedrich, LLP and/or Quarles & Brady, LLP along with the right to use these forms as part of KBC’s consulting services to KBC clients. As a KBC client, the undersigned also acknowledges that the paid consulting fee gives the organization represented by the undersigned the single-use right to utilize (but not to download) the materials received to create and modify that organization’s individual HIPAA compliance manual and policies and procedures for its health plans. It does not provide the right to share such copyrighted information forms, manuals, etc. with another organization for their compliance.

The undersigned further acknowledges their responsibility and authority to assure that all current, former and future employees of the organization abide by this copyright ownership and statement of allowed use agreement.

1) Please paste your cursor over the signature box and draw your signature with mouse, finger or touch. OR 2) Type your name in the box. Either option will act as your signature."

Signature:


Online Version

HIPAA Privacy Compliance
Request Form

Online Program Available September 2018!

Type of Organization: School DistrictMunicipalityCorporationOther

Do You Have: Long Term Care InsuranceVision InsuranceEmployee Assistance PlanHRA