Completion Instructions
- 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 when explanation or documentation is requested.
- Attach supporting documentation where referenced (BAA, SOC 2, pen test report, BCP attestation, etc.) by describing it in the Comments field; your Valor contact will request files separately.
- Questions marked PHI relate specifically to Protected Health Information under HIPAA. All vendors handling Valor 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 Valor Information Security contact securely.
Vendor Information
Protected Health Information (PHI)
Electronic PHI (ePHI)
Patient / Employee PII
Financial / Billing Data
Clinical / Pharmacy Data
Auth Credentials
Internal Valor Operational Data
None
Yes — listed in comments
No
Vendor Attestation & Signature
By signing below, the authorized representative of the vendor organization attests that the information provided in this questionnaire is accurate and complete to the best of their knowledge, that the vendor organization will promptly notify Valor Compounding Pharmacy of any material changes to the information provided, and that the vendor understands its obligations under any executed Business Associate Agreement (BAA) with Valor Compounding Pharmacy.
- The information provided in this questionnaire is true, accurate, and complete to the best of my knowledge.
- I am authorized to provide this information on behalf of my organization.
- My organization will notify Valor Compounding Pharmacy within 24 hours of any confirmed or suspected incident affecting Valor patient data, PHI, or systems.
- My organization acknowledges its obligations under any executed HIPAA Business Associate Agreement (BAA) with Valor Compounding Pharmacy.
- My organization will notify Valor Compounding Pharmacy of material changes to this questionnaire's responses within 30 days of such change.