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(Internal Form) Issued by County of San Mateo Contract Compliance Committee August 6, 2013 <br />County of San Mateo <br />Health Insurance Portability and Accountability Act (HIPAA) <br />Questionnaire <br /> <br />Date: 2/10/2022 <br />Contractor Name: City of Redwood City – Redwood City Together <br />Contract Administrator: Juvy Ann Reyes <br /> <br />Answer the following questions to determine if the Contractor is Business Associate <br /> 1. Will the County disclose individually identifiable health information concerning County <br />clients to the contractor? <br /> <br />☐ YES (if this box is checked, go directly to question #3) <br />☒ NO (if this box is checked, respond to question #2) <br /> <br />2. Will the Contractor use individually identifiable health information concerning County <br />clients in the process of providing services for the County? <br /> <br />☐ YES <br />☒ NO <br /> If you responded “NO” to both questions #1 and #2 then stop here. This is not a Business <br />Associate. If you answered “YES” to either #1 or #2, then proceed to question #3 <br /> <br />3. Will the Contractor use the identifiable health information ONLY to provide direct <br />physical/mental health care or treatment to clients of the County? <br /> <br />☐ YES (if this box is checked, this is not a business associate) <br />☐ NO (if this box is checked, the contractor IS a business associate) <br /> <br />4. Explain the services provided by the Contractor: <br />Contractor will implement Redwood City (RWC) Neighborhood Action Team project <br />to develop and implement grassroots efforts aimed at increasing access to mental <br />health services for community members most impacted by the COVID pandemic. <br /> <br />Name of person completing/approving this form: Marc Meulman <br /> Director of Public Health, Policy and Planning <br />Date: <br /> <br />Approved By: <br />Questions about HIPAA should be directed to the San Mateo County HIPAA Privacy Officer and/or County Counsel. <br />DocuSign Envelope ID: 48103F1F-8EC3-4EF4-AA5B-D8465A300A24 <br />9/27/2022 | 8:44 AM PDT