HIPAA Security Policy and Procedures Templates (Updated for HITECH)

The HIPAA Security policy and procedures template suite contains 71 policies of which is a real timesaver since it will save you 400 working hours and still give you all the implementation specification details on the HIPAA security policies. These templates have been tailored to HIPAA requirements, contain updates from NIST Standards, Security Best practices, HITECH act, and Omnibus rule of 2013. These policies were formulated with the main objective being to ensure that they concurred with the regulations of HIPAA security; the best security practices integrated with the security industry; and customized to meet the needs of a healthcare entity environment.

Our HIPAA Security policy and procedures templates are tailored to suit covered entities, business associates, and sub-vendors.

These templates are compiled in such a manner that you won’t need to refer to external resources to get acquainted with HIPAA Security policy and procedures.

These 71 HIPAA Security Policies in the template suite (updated in August 2013) are organized into the following five major categories:

Category of Policies & Procedures
Total Policies and Procedures
Administrative Safeguards
31
Physical Safeguards
13
Technical Safeguards
12
Organizational Requirements
04
Supplemental Policies to required policy
11

 

I. POLICIES ON THE STANDARDS FOR ADMINISTRATIVE SAFEGUARDS
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).
(Standard.) Describes processes the organization implements to prevent, detect, contain, and correct security violations relative to its ePHI.
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.)
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.)
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.)
Describes processes for regular organizational review of activity on its information systems containing ePHI. (Required Implementation Specification for the Security Management Process standard.)
(Standard.) Describes the requirements for the responsibilities of the Information Security Officer.
(Standard.) Describes what the organization should do to ensure ePHI access occurs only by employees who have been appropriately authorized.
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.)
Reviews what the organization should do to ensure that employee access to its ePHI is appropriate. (Addressable Implementation Specification for Workforce Security standard.)
Defines what the organization should do to prevent unauthorized access to its ePHI by former employees. (Addressable Implementation Specification for Workforce Security standard.)
(Standard.) Indicates what the organization should do to ensure that only appropriate and authorized access is made to its ePHI.
defines how the organization provides authorized access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)
Discusses what the organization should do to establish, document, review, and modify access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)
(Standard.) Describes elements of the organizational program for regularly providing appropriate security training and awareness to its employees.
Defines what the organization should do to provide ongoing security information and awareness to its employees. (Addressable Implementation Specification for Security Awareness & Training standard.)
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.)
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.)
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.)
(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.
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.)
(Standard.) Identifies what the organization should do to be able to effectively respond to emergencies or disasters that impact its ePHI.
Discusses organizational processes to regularly back up and securely store ePHI. (Required Implementation Specification for Contingency Plan standard.)
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.)
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.)
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.)
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.)
(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.
(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.
(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.
Provide guidance to Covered Entities regarding the execution of business associate contracts.
II. POLICIES ON THE STANDARDS FOR PHYSICAL SAFEGUARDS
(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.
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.)
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.)
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.)
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.)
(Standard.) Indicates what the organization should do to appropriately protect its workstations.
(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.
(Standard.) Discusses what the organization should do to appropriately protect information systems and electronic media containing PHI that are moved to various organizational locations.
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.)
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.)
Discusses what the organization should do specifically addressing mobile device security in support of the Device and Media Controls Standard.)
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.)
Discusses what the organization should do to back up and securely store ePHI on its information systems and electronic media. (Addressable Implementation Specification for Device and Media Controls standard.)
III. POLICIES ON THE STANDARDS FOR TECHNICAL SAFEGUARDS
(Standard.) Indicates what the organization should do to purchase and implement information systems that comply with its information access management policies.
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.)
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.)
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.)
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.)
(Standard.) Discusses what the organization should do to record and examine significant activity on its information systems that contain or use ePHI.
(Standard.) Defines what the organization should do to appropriately protect the integrity of its ePHI.
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.)
(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.
(Standard.) Describes what the organization should do to appropriately protect the confidentiality, integrity, and availability of the ePHI it transmits over electronic communications networks.
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.)
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
(Standard.) Defines what the requirements are relative to establishing organizational policies and procedures.
(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.
The purpose is to implement policies and procedures that protect the electronic protected health information of the clearinghouse from unauthorized access by the larger organization (Required Implementation Specification for Information Access Management standard.)
(Standard.) The purpose is to ensure that reasonable and appropriate safeguards are maintained on electronic 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
The purpose is to implement security measures sufficient to reduce risks and vulnerabilities of the wireless infrastructure.
The purpose is to establish management direction, procedures, and requirements to ensure the safe and successful delivery of e-mail.
The purpose is to explain Company’s analog and ISDN line acceptable use and approval policies and procedures.
The purpose is to implement security measures sufficient to reduce risks and vulnerabilities of dial-in connections to the enterprise infrastructure
The purpose is to prevent the unauthorized or inadvertent disclosure of sensitive company information.
The purpose is to implement security measures sufficient to reduce risks and vulnerabilities of remote access connections to the enterprise infrastructure.
The purpose is to establish a culture of openness, trust, and integrity in business practices.
The purpose is to implement security measures sufficient to reduce the risks and vulnerabilities of the VPN infrastructure
The purpose is to describe the policy under which third-party organizations connect to the Company’s networks for the purpose of transacting business related to the Company
The purpose is to define standards to be met by all equipment owned and/or operated by the Company located outside Company’s corporate Internet firewalls.
The purpose is to establish requirements for information processed by computer networks.

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