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Sample Policy

I.1         HIPAA Security Policy #1 General Security Compliance                       

 

<Company>

HIPAA Security Policy #1

 

General Security Compliance

 

Reference:      HIPAA Security standard:     164.308(a)(1)

                                                                        164.308(a)(6)

 

Statement of Policy

 

<Company> is committed to conduct business in compliance with all applicable laws, regulations and <Company> policies. <Company> has adopted this policy to set forth its compliance with those standards established by the Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") regarding the security of Electronic Protected Health Information ("EPHI") (the "Security Regulations").

 

Scope of Policy

 

The scope of this Policy covers <Company>’s general approach to compliance with the Security Regulations. As a covered entity under the Security Regulations, <Company> must: (1) ensure the confidentiality, integrity and availability of all EPHI <Company> creates, receives, maintains or transmits; (2) protect against any reasonably anticipated threats or hazards to the security or integrity of such information; (3) protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required; and (4) ensure compliance with the Security Regulations by its Workforce. Compliance with the Security Regulations will require <Company> to implement:

 

  • Administrative Safeguards--those actions, policies and procedures to manage the selection, development, implementation and maintenance of security measures to protect EPHI and to manage the conduct of <Company>’s Workforce in relation to the protection of and authorized access to said EPHI.
  • Physical Safeguards--those physical measures, policies and procedures to protect <Company>’s electronic information systems, related buildings and equipment from natural and environmental hazards and unauthorized intrusion.
  • Technical Safeguards--the technologies and the policies and procedures for its use that protect EPHI and control access to it.

 

The specifications for implementation of each of these safeguards are addressed in three separate sets of policies. The Administrative Safeguards are set forth in HIPAA Security Policies #1 through 8; the Physical Safeguards are set forth in HIPAA Security Policies #9 through 12; and the Technical Safeguards are set forth in HIPAA Security Policies #13 through 17.

 

Policy

I.1.1        Security Personnel and Implementation

<Company> has designated a Security Officer with overall responsibility for the development and implementation of policies that conform to the Security Regulations ("Security Policies"). The initial HIPAA Security Officer is <name>, HIPAA Security Officer, and Information Technology Manager for <Company>. The Security Officer is responsible for ensuring that <Company>: (i) complies with the HIPAA Security Policies, (ii) develops and implements business HIPAA security procedures ("Security Procedures") for each Security Policy, (iii) maintains the confidentiality of all EPHI created or received by <Company> from the date such information is created or received until it is destroyed, and (iv) trains all Workforce members the appropriate level of HIPAA training as determined.  The Security Regulations permit <Company> to implement any security measure that allows it to reasonably and appropriately comply with a specific security standard in the Security Regulations. In determining which security measures to implement, <Company> must take in to account its size, complexity and capabilities; technical infrastructure; hardware and software security capabilities; the costs of the security measures; and the probability and criticality of potential risks to EPHI.

I.1.2        Security Policies and Procedures

 

The <Company> HIPAA Security Policies and Security Procedures are designed to ensure compliance with the Security Regulations. Such Security Policies and Security Procedures shall be kept current and in compliance with any changes in the law, regulations or practices of <Company> in accordance with HIPAA Security Policy #8 - Periodic Evaluation of Security Policies and Procedures.

I.1.3        Responsibility of All Employees within <Company>

 

Every member of the <Company> Workforce is responsible for being aware of, and complying with, the Security Regulations and the Security Policies and Security Procedures.

 

Creation Date:

Effective Date:

Last Revision Date:

 

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