Effective Date: 07/25/2023
Updated: 07/25/2023
Introduction
[business_name_short] is committed to ensuring the privacy and security of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and its applicable regulations. This policy outlines our commitment to HIPAA compliance and the measures we have implemented to protect PHI. [business_name_short] creates, receives, maintains, and in some instances discloses protected health information (PHI) in an electronic format. Though such electronic disclosures are in accordance with the Health Insurance Portability and Accountability Act, this posted notice is provided to satisfy the Arizona and Safety Code (Notice and Authorization Required for Electronic Disclosure of Protected Health Information; Exceptions).To that end, [business_name_short] will secure a separate authorization from the patient or the patient’s legally authorized representative prior to electronically disclosing PHI for any reason other than treatment, payment, health care operations, or as otherwise authorized or required by law.
Scope of Policy
This policy applies to all employees, contractors, and business associates of [business_name_short] who have access to PHI in the course of their work.
Policy Statement
- HIPAA Compliance Responsibility: [business_name_short] acknowledges its responsibility to comply with HIPAA regulations and protect the confidentiality, integrity, and availability of PHI.
- Designated HIPAA Privacy and Security Officers: [business_name_short] has designated a HIPAA Privacy Officer and a HIPAA Security Officer who are responsible for overseeing the development, implementation, and maintenance of HIPAA compliance initiatives.
- Risk Assessment and Management: [business_name_short] conducts regular risk assessments to identify vulnerabilities and threats to the privacy and security of PHI. Appropriate safeguards are implemented to manage and mitigate identified risks.
- Privacy and Security Policies and Procedures: [business_name_short] maintains comprehensive policies and procedures that address the privacy and security requirements of HIPAA. These policies and procedures are regularly reviewed, updated, and communicated to all employees.
- Workforce Training and Education: [business_name_short] provides HIPAA training to all employees, contractors, and business associates who handle PHI. Training includes the importance of privacy and security, handling of PHI, reporting security incidents, and individual responsibilities.
- Physical Safeguards: [business_name_short] implements physical safeguards to restrict access to areas where PHI is stored. These safeguards include secure storage, access controls, and visitor policies.
- Technical Safeguards: [business_name_short] implements technical safeguards to protect electronic PHI (ePHI) from unauthorized access, disclosure, and alteration. These safeguards include access controls, encryption, firewalls, malware protection, and regular security updates.
- Administrative Safeguards: [business_name_short] establishes administrative safeguards to manage the HIPAA compliance program. This includes policies and procedures for incident response, business associate agreements, workforce sanctions, and ongoing monitoring and auditing.
- Business Associate Management: [business_name_short] enters into written agreements with business associates that require them to appropriately safeguard PHI and comply with HIPAA regulations.
- Breach Notification: [business_name_short] has established procedures for assessing and responding to security incidents involving PHI. In the event of a breach, affected individuals and regulatory authorities will be notified as required by law.
- Complaints and Reporting: [business_name_short] maintains a process for individuals to file complaints regarding potential HIPAA violations or concerns. All complaints are promptly investigated, and appropriate corrective actions are taken.
HIPPA Compliance Officer
For questions or concerns regarding HIPAA compliance or the protection of PHI, please send an email with Attention: HIPPA Compliance Officer to [business_email] [business_name_hippa_compliance_officer] [business_address_line_one] [business_address_line_two]
Telephone: [business_number]
Email: [business_email]