9 Core Elements of a
HIPAA Manual

9 Core Elements of a HIPAA Manual

🔴 1.  HIPAA Policies and Procedures

• Privacy Policies: Detailed policies on how patient information is collected, used, and disclosed.

• Security Policies: Measures to protect electronic protected health information (ePHI), including administrative, physical, and technical safeguards.

• Breach Notification Policies: Procedures for identifying, responding to, and reporting breaches of PHI.

• Schedule of Audits/Training Log

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🔴 2.  Patient Rights - Forms & Notices

• Notice of Privacy Practices (NPP): Informing patients of their rights under HIPAA and how their information will be used.

• Access to PHI: Procedures for patients to access their own health information.

• Amendments to PHI: Processes for patients to request corrections to their health information.

• Accounting of Disclosures: Providing patients with a record of when and why their information has been shared.

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🔴 3.  Vendor and Organizational Requirements

• Business Associate Agreements: Contracts with third parties that ensure they comply with HIPAA when handling ePHI.

• Complaint Procedures: Processes for patients to file complaints regarding HIPAA violations.

• Documentation Requirements: Guidelines for maintaining HIPAA related documentation.

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🔴 4. Physical Safeguards

• Facility Access Controls: Measures to control physical access to areas where ePHI is stored.

• Workstation Use and Security: Guidelines for the proper use of workstations that access ePHI.

• Device and Media Controls: Policies for handling and disposing of electronic devices and media that contain ePHI.

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🔴 5. Administrative Safeguards

• Risk Analysis and Management: Regular assessments to identify potential risks to ePHI and steps to mitigate these risks.

• Sanction Policy: Disciplinary actions for employees who violate HIPAA policies.

• Workforce Training: Regular HIPAA training for all staff members to ensure compliance.

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🔴 6. Technical Safeguards

• Access Controls: Policies for ensuring that only authorized personnel have access to ePHI.

• Audit Controls: Procedures for tracking and monitoring access to ePHI.

• Integrity Controls: Measures to ensure that ePHI is not altered or destroyed in an unauthorized manner.

• Transmission Security: Guidelines for protecting ePHI during electronic transmission.

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🔴 7.  Incident Response and Reporting

• Incident Response Plan: Steps to take in the event of a security incident or breach.

• Breach Notification: Detailed procedures for notifying affected individuals, the Department of Health and Human Services (HHS), and potentially the media in case of a significant breach.

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🔴 8. Regular Reviews and Updates

• Annual Review: Regularly reviewing and updating the HIPAA manual to ensure compliance with new regulations and changes in the practice.

• Continuous Improvement: Implementing changes based on audit findings, risk assessments, and feedback from staff and patients.

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🔴 9. Resources

•  Templates and Forms: Sample forms and templates for documenting HIPAA compliance activities.

• Resources: Links to additional resources, such as HHS guidelines and compliance checklists.