Complete all fields in the Vendor Information section below.

For each question, select Yes, No, or N/A.

Use the Evidence / Comments field to support your response — especially where explanation or documentation is requested.

Attach supporting documentation where referenced (BAA, SOC 2, pen test report, BCP attestation, etc.).

Questions marked PHI relate specifically to Protected Health Information under HIPAA. All vendors handling PHS PHI must have an executed Business Associate Agreement (BAA) on file prior to engagement.

An authorized representative must complete and submit the Attestation at the end. Return to your designated PHS Information Security contact securely.