This Information Management Agreement (IMA) template is intended to be adapted by custodians to document the collection, storage, and disclosure of health information as required under the Health Information Act (HIA).
An Information Manager is defined under the HIA as a person or body that:
- Processes, stores, retrieves, or disposes of health information
- Strips, encodes, or otherwise transforms individually identifying health information to create non-identifying health information
- Provides information management or information technology (IT) services
An IMA should be used for:
- Electronic medical record (EMR) vendor
- Billing agent or transcription service
- Storage facility for electronic or paper records
- IT service provider/company
Instructions for Use
These instructions are meant to help you make this IMA template your own and fulfill your obligations under the HIA.
- State the name of the Lead Custodian on Page 1.
- The Information Manager is the company (or individual) who provides the service described above.
- Appointment and Duties of the Information Manager: fill in the name of the company or individual named on Page 1.
- Terms and Termination: a term between one to five years is recommended or for the length of the service agreement. An IMA should be reviewed periodically, updated if needed and signed by all parties.
- Notices: the agreements must be signed and dated by the authorized representatives.
- Schedule A: clinics with more than one physician often delegate one of the physicians in the clinic as Lead Custodian. This physician can be named as the authorized representative. The authorized representative becomes the signatory to the agreement on behalf of all clinic physicians.
- Schedule B: should contain a listing of the tasks or services provided by the Information Manager. These can often be found in a service agreement with the provider. Cutting and pasting the tasks from the service agreement or referencing the service agreement are both appropriate.
IMA for Primary Care Networks
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