Business Associate Agreement Request Form

Any customer expecting to receive calls from patients may request a Business Associate Agreement. Please complete the following form and allow 2 business days to receive your copy with instructions on how to complete the process.

Please provide the following information exactly as you want it to appear on the Agreement. Since this is a legal agreement, all names, company names, and other information should be legally accurate. If there are multiple providers on an account with RingRx that operate as individual providers, each one will need to complete their own BAA and therefore their own form. Submit one form per individual. If the provider is a company, just complete one form for the entity with the Compliance Officer of the entity as the Requester Name the compliance officer.

  • (Spell exactly as you want it to appear on the agreement, including punctuation and suffixes, if any)