HIPAA Security Policies Templates

View Sample HIPAA Security Policy

I. HIPAA SECURITY POLICIES ON THE STANDARDS FOR ADMINISTRATIVE SAFEGUARDS

1. Breach Notification Policy-

The purpose of this policy is to define how the Covered Entity will respond to security and/or privacy incidents or suspected privacy and/or security incidents that result in a breach of protected health information (PHI).

2. Security Management Process-

(Standard.) Describes processes the organization implements to prevent, detect, contain, and correct security violations relative to its ePHI.

3. Risk Analysis-

Discusses what the organization should do to identify, define, and prioritize risks to the confidentiality, integrity, and availability of its ePHI. (Required Implementation Specification for the Security Management Process standard.)

4. Risk Management-

Defines what the organization should do to reduce the risks to its ePHI to reasonable and appropriate levels. (Required Implementation Specification for the Security Management Process standard.)

5. Sanction Policy-

Indicates actions that are to be taken against employees who do not comply with organizational security policies and procedures. (Required Implementation Specification for the Security Management Process standard.)

6. Information System Activity Review-

Describes processes for regular organizational review of activity on its information systems containing ePHI. (Required Implementation Specification for the Security Management Process standard.)

7. Assigned Security Responsibility-

(Standard.) Describes the requirements for the responsibilities of the Information Security Officer.

8. Workforce Security-

(Standard.) Describes what the organization should do to ensure ePHI access occurs only by employees who have been appropriately authorized.

9. Authorization and/or Supervision-

Identifies what the organization should do to ensure that all employees who can access its ePHI are appropriately authorized or supervised. (Required Implementation Specification for the Workforce Security standard.)

10. Workforce Clearance Procedure-

Reviews what the organization should do to ensure that employee access to its ePHI is appropriate. (Addressable Implementation Specification for Workforce Security standard.)

11. Termination Procedures-

Defines what the organization should do to prevent unauthorized access to its ePHI by former employees. (Addressable Implementation Specification for Workforce Security standard.)

12. Information Access Management-

(Standard.) Indicates what the organization should do to ensure that only appropriate and authorized access is made to its ePHI.

13. Access Authorization-

Defines how the organization provides authorized access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)

14. Access Establishment and Modification-

Discusses what the organization should do to establish, document, review, and modify access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)

15. Security Awareness & Training-

(Standard.) Describes elements of the organizational program for regularly providing appropriate security training and awareness to its employees.

16. Security Reminders-

Defines what the organization should do to provide ongoing security information and awareness to its employees. (Addressable Implementation Specification for Security Awareness & Training standard.)

17. Protection from Malicious Software-

Indicates what the organization should do to provide regular training and awareness to its employees about its process for guarding against, detecting, and reporting malicious software. (Addressable Implementation Specification for Security Awareness & Training standard.)

18. Log-in Monitoring-

Discusses what the organization should do to inform employees about its process for monitoring log-in attempts and reporting discrepancies. (Addressable Implementation Specification for Security Awareness & Training standard.)

19. Password Management-

Describes what the organization should do to maintain an effective process for appropriately creating, changing, and safeguarding passwords. (Addressable Implementation Specification for Security Awareness & Training standard.)

20. Security Incident Procedures-

(Standard.) Discusses what the organization should do to maintain a system for addressing security incidents that may impact the confidentiality, integrity, or availability of its ePHI.

21. Response and Reporting-

Defines what the organization should do to be able to effectively respond to security incidents involving its ePHI. (Required Implementation Specification for Security Incident Procedures standard.)

22. Contingency Plan-

(Standard.) Identifies what the organization should do to be able to effectively respond to emergencies or disasters that impact its ePHI.

23. Data Backup Plan-

Discusses organizational processes to regularly back up and securely store ePHI. (Required Implementation Specification for Contingency Plan standard.)

24. Disaster Recovery Plan-

Indicates what the organization should do to create a disaster recovery plan to recover ePHI that was impacted by a disaster. (Required Implementation Specification for Contingency Plan standard.)

25. Emergency Mode Operation Plan-

Discusses what the organization should do to establish a formal, documented emergency mode operations plan to enable the continuance of crucial business processes that protect the security of its ePHI during and immediately after a crisis situation. (Required Implementation Specification for Contingency Plan standard.)

26. Testing and Revision Procedure-

Describes what the organization should do to conduct regular testing of its disaster recovery plan to ensure that it is up-to-date and effective. (Addressable Implementation Specification for Contingency Plan standard.)

27. Applications and Data Criticality Analysis-

Reviews what the organization should do to have a formal process for defining and identifying the criticality of its information systems. (Addressable Implementation Specification for Contingency Plan standard.)

28. Evaluation-

(Standard.) Describes what the organization should do to regularly conduct a technical and non-technical evaluation of its security controls and processes in order to document compliance with its own security policies and the HIPAA Security Rule.

29. Business Associate Contracts and Other Arrangements-

(Standard.) Describes how to establish agreements that should exist between the organization and its various business associates that create, receive, maintain, or transmit ePHI on its behalf.

30. Business Associate Agreement-

(Standard.) Describes how to establish agreements that should exist between the organization and its various business associates that create, receive, maintain, or transmit ePHI on its behalf.

31. Execution of Business Associate Agreements with Contracts-

Provide guidance to Covered Entities regarding the execution of business associate contracts.

II. HIPAA SECURITY POLICIES ON THE STANDARDS FOR PHYSICAL SAFEGUARDS

32. Facility Access Controls-

(Standard.) Describes what the organization should do to appropriately limit physical access to the information systems contained within its facilities while ensuring that properly authorized employees can physically access such systems.

33. Contingency Operations-

Identifies what the organization should do to have formal, documented procedures for allowing authorized employees to enter its facility to take necessary actions as defined in its disaster recovery and emergency mode operations plans. (Addressable Implementation Specification for Facility Access Controls standard.)

34. Facility Security Plan-

Discusses what the organization should do to establish a facility security plan to protect its facilities and the equipment therein. (Addressable Implementation Specification for Facility Access Controls standard.)

35. Access Control and Validation Procedures-

Discusses what the organization should do to appropriately control and validate physical access to its facilities containing information systems having ePHI or software programs that can access ePHI. (Addressable Implementation Specification for Facility Access Controls standard.)

36. Maintenance Records-

Defines what the organization should do to document repairs and modifications to the physical components of its facilities related to the protection of its ePHI. (Addressable Implementation Specification for Facility Access Controls standard.)

37. Workstation Use-

(Standard.) Indicates what the organization should do to appropriately protect its workstations.

38. Workstation Security-

(Standard.) Reviews what the organization should do to prevent unauthorized physical access to workstations that can access ePHI while ensuring that authorized employees have the appropriate access.

39. Device and Media Controls-

(Standard.) Discusses what the organization should do to appropriately protect information systems and electronic media containing PHI that are moved to various organizational locations.

40. Disposal-

Describes what the organization should do to appropriately dispose of information systems and electronic media containing ePHI when it is no longer needed. (Required Implementation Specification for Device and Media Controls standard.)

41. Media Re-use-

Discusses what the organization should do to erase ePHI from electronic media before re-using the media. (Required Implementation Specification for Device and Media Controls standard.)

42. Mobile Device Policy-

Discusses what the organization should do specifically addressing mobile device security in support of the Device and Media Controls Standard.)

43. Accountability-

Defines what the organization should do to appropriately track and log all movement of information systems and electronic media containing ePHI to various organizational locations. (Addressable Implementation Specification for Device and Media Controls standard.)

44. Data Backup and Storage-

Discusses what the organization should do to backup and securely store ePHI on its information systems and electronic media. (Addressable Implementation Specification for Device and Media Controls standard.)

III. HIPAA SECURITY POLICIES ON THE STANDARDS FOR TECHNICAL SAFEGUARDS

45. Access Control-

(Standard.) Indicates what the organization should do to purchase and implement information systems that comply with its information access management policies.

46. Unique User Identification-

Discusses what the organization should do to assign a unique identifier for each of its employees who access its ePHI for the purpose of tracking and monitoring the use of information systems. (Required Implementation Specification for Access Control standard.)

47. Emergency Access Procedure-

Discusses what the organization should do to have a formal, documented emergency access procedure enabling authorized employees to obtain required ePHI during the emergency. (Required Implementation Specification for Access Control standard.)

48. Automatic Logoff-

Discusses what the organization should do to develop and implement procedures for terminating users’ sessions after a certain period of inactivity on systems that contain or have the ability to access ePHI. (Addressable Implementation Specification for Access Control standard.)

49. Encryption and Decryption-

Discusses what the organization should do to appropriately use encryption to protect the confidentiality, integrity, and availability of its ePHI. (Addressable Implementation Specification for Access Control standard.)

50. Audit Controls-

(Standard.) Discusses what the organization should do to record and examine significant activity on its information systems that contain or use ePHI.

51. Integrity-

(Standard.) Defines what the organization should do to appropriately protect the integrity of its ePHI.

52. Mechanism to Authenticate Electronic Protected Health Information-

Discusses what the organization should do to implement appropriate electronic mechanisms to confirm that its ePHI has not been altered or destroyed in any unauthorized manner. (Addressable Implementation Specification for Integrity standard.)

53. Person or Entity Authentication-

Standard.) Defines what the organization should do to ensure that all persons or entities seeking access to its ePHI are appropriately authenticated before access is granted.

54. Transmission Security-

(Standard.) Describes what the organization should do to appropriately protect the confidentiality, integrity, and availability of the ePHI it transmits over electronic communications networks.

55. Integrity Controls-

Indicates what the organization should do to maintain appropriate integrity controls that protect the confidentiality, integrity, and availability of the ePHI it transmits over electronic communications networks. (Addressable Implementation Specification for Transmission Security standard.)

56. Encryption-

Defines what the organization should do to appropriately use encryption to protect the confidentiality, integrity, and availability of ePHI it transmits over electronic communications networks. (Addressable Implementation Specification for Transmission Security standard.)

IV. ORGANIZATIONAL REQUIREMENTS

57. Policies and Procedures-

(Standard.) Defines what the requirements are relative to establishing organizational policies and procedures.

58. Documentation-

(Standard.) Discusses what the organization should do to appropriately maintain, distribute, and review the security policies and procedures it implements to comply with the HIPAA Security Rule.

59. Isolating Healthcare Clearinghouse Function-

The purpose is to implement policies and procedures that protect the electronically protected health information of the clearinghouse from unauthorized access by the larger organization (Required Implementation Specification for Information Access Management standard.)

60. Group Health Plan Requirements-

(Standard.) The purpose is to ensure that reasonable and appropriate safeguards are maintained on electronically protected health information created, received, maintained, or transmitted to or by the plan sponsor on behalf of the group health plan.

V. SUPPLEMENTAL POLICIES FOR REQUIRED POLICIES

61. Wireless Security Policy-

The purpose is to implement security measures sufficient to reduce risks and vulnerabilities to the wireless infrastructure.

62. Email Security Policy-

The purpose is to establish management direction, procedures, and requirements to ensure the safe and successful delivery of e-mail.

63. Analog Line Policy-

The purpose is to explain the Company’s analog and ISDN line acceptable use and approval policies and procedures.

64. Dial-in Access Policy-

The purpose is to implement security measures sufficient to reduce risks and vulnerabilities of dial-in connections to the enterprise infrastructure.

65. Automatically Forwarded Email Policy-

The purpose is to prevent unauthorized or inadvertent disclosure of sensitive company information.

66. Remote Access Policy-

The purpose is to implement security measures sufficient to reduce risks and vulnerabilities of remote access connections to the enterprise infrastructure.

67. Ethics Policy-

The purpose is to establish a culture of openness, trust, and integrity in business practices.

68. VPN Security Policy-

The purpose is to implement security measures sufficient to reduce the risks and vulnerabilities of the VPN infrastructure

69. Extranet Policy-

The purpose is to describe the policy under which third party organizations connect to Company’s networks to transact business related to Company

70. The Internet DMZ Equipment Policy-

The purpose is to define standards to be met by all equipment owned and/or operated by a Company located outside the Company’s corporate Internet firewalls.

71. Network Security Policy-

The purpose is to establish requirements for information processed by computer networks.

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