Gradient AI Pre-Screen Request — Unity Operations Playbook

Unity Care Solutions — Gradient AI Pre-Screen Request

Internal / Confidential — PHI must not be submitted without executed BAA

⚠️ BAA REQUIRED BEFORE SUBMISSION

A Business Associate Agreement with Gradient AI must be fully executed before any Protected Health Information (PHI) is submitted. Verify BAA status in the Vendor Directory. Do not proceed if BAA is pending.

Employer / Group Details

Employer Name *

EIN

Contact Name *

Expected Employee Count

Effective Date

Census Submission

Census File Instructions: Do not attach census files to this form. Census data must be submitted directly to Gradient AI via their secure portal or encrypted email channel. Before sending, verify:

All data is de-identified per HIPAA minimum necessary standard
No Social Security Numbers, full birth dates, or member names included
12–24 months of prior claims data attached if available
Current carrier and plan type documented in your submission note

Submission Notes

Notes / Special Considerations

Required Acknowledgments — Must check both before submitting

BAA Confirmed — I confirm that a Business Associate Agreement with Gradient AI has been fully executed and is on file. No PHI will be submitted without this confirmation. REQUIRED before submit

PHI Data Handling Acknowledgment — I acknowledge that this submission may contain Protected Health Information (PHI) and that handling must comply with HIPAA minimum necessary standards and the executed BAA with Gradient AI. REQUIRED before submit