HIPAA Administrative Safeguards Profile, v1.0

Profile of the requirements in the HIPAA Administrative Safeguards section (164.308) by collecting all the relevant TIPs and TDs.
Identifier https://artifacts.trustmarkinitiative.org/lib/tips/hipaa-administrative-safeguards-profile/1.0/
Publication Date 2017-02-17
Issuing Organization
No Responder help@trustmarkinitiative.org 404-407-8956 75 5th Street NW, Suite 900, Atlanta, GA 30308
Keywords There are no keywords.
Legal Notice This document and the information contained herein is provided on an "AS IS" basis, and the Georgia Tech Research Institute disclaims all warranties, express or implied, including but not limited to any warranty that the use of the information herein will not infringe any rights or any implied warranties or merchantability or fitness for a particular purpose. In addition, the Georgia Tech Research Institute disclaims legal liability for any loss incurred as a result of the use or reliance on the document or the information contained herein.
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Trust Expression:

TIP_HIPAASecurityManagementProcessProfile and TD_AssignedSecurityResponsibility and TIP_HIPAAWorkforceSecurityProfile and TIP_HIPAAInformationAccessManagementPoliciesProfile and TIP_HIPAAInformationAccessManagementProceduresProfile and TIP_HIPAASecurityAwarenessandTrainingProfile and TIP_HIPAASecurityIncidentPoliciesProfile and TIP_HIPAASecurityIncidentProceduresProfile and TIP_HIPAAContingencyPlanPolicies and TIP_HIPAAContingencyPlanProcedures and TIP_HIPAAPeriodicSecurityPolicyEvaluationProfile and TIP_HIPAAPeriodicSecurityProceduresEvaluationProfile

References (12)

 TIP  HIPAA Security Management Process Profile, v1.0
Description Profile of HIPAA Security Management requirements (per 45 CFR Section 164.308(a)(1)) for a covered entity or business associate to implement policies and procedures to prevent, detect, contain, and correct security violations.
ID TIP_HIPAASecurityManagementProcessProfile
 TIP  HIPAA Workforce Security Profile, v1.0
Description Profile of HIPAA Information Access Management (per 45 CFR Section 164.308(a)(3)) covered entity or business associate requirements to ensure members of its workforce have appropriate access and to prevent inappropriate access to electronic protected health information (e-PHI).
ID TIP_HIPAAWorkforceSecurityProfile
 TIP  HIPAA Information Access Management Policies Profile, v1.0
Description Profile of HIPAA Information Access Management (per 45 CFR Section 164.308(a)(4)) requirements for policies for authorizing access to e-PHI.
ID TIP_HIPAAInformationAccessManagementPoliciesProfile
 TIP  HIPAA Information Access Management Procedures Profile, v1.0
Description Profile of HIPAA Information Access Management (per 45 CFR Section 164.308(a)(4)) requirements for procedures for authorizing access to e-PHI.
ID TIP_HIPAAInformationAccessManagementProceduresProfile
 TIP  HIPAA Security Awareness and Training Profile, v1.0
Description Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.308(a)(5)) requirements for a covered entity or business associate to implement a security awareness and training program for all members of its workforce (including management).
ID TIP_HIPAASecurityAwarenessandTrainingProfile
 TIP  HIPAA Security Incident Policies Profile, v1.0
Description Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.308(a)(6)) requirements for a covered entity or business associate to implement policies to address security incidents.
ID TIP_HIPAASecurityIncidentPoliciesProfile
 TIP  HIPAA Security Incident Procedures Profile, v1.0
Description Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.308(a)(6)) requirements for a covered entity or business associate to implement procedures to address security incidents.
ID TIP_HIPAASecurityIncidentProceduresProfile
 TIP  HIPAA Contingency Plan Policies, v1.0
Description Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.308(a)(7)) requirements for a covered entity or business associate to establish policies for responding to an emergency or other occurrence (for example, fire, vandalism, system failure, and natural disaster) that damages systems that contain electronic protected health information.
ID TIP_HIPAAContingencyPlanPolicies
 TIP  HIPAA Contingency Plan Procedures, v1.0
Description Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.308(a)(7)) requirements for a covered entity or business associate to establish (and implement as needed) procedures for responding to an emergency or other occurrence (for example, fire, vandalism, system failure, and natural disaster) that damages systems that contain electronic protected health information.
ID TIP_HIPAAContingencyPlanProcedures
 TIP  HIPAA Periodic Security Policy Evaluation Profile, v1.0
Description Profile of HIPAA required periodic technical and non-technical policy evaluation, based initially upon the standards implemented under this rule and, subsequently, in response to environmental or operational changes affecting the security of electronic protected health information, per 45 CFR Section 164.308(a)(8).
ID TIP_HIPAAPeriodicSecurityPolicyEvaluationProfile
 TIP  HIPAA Periodic Security Procedures Evaluation Profile, v1.0
Description Profile of HIPAA required periodic technical and non-technical procedures evaluation, based initially upon the standards implemented under this rule and, subsequently, in response to environmental or operational changes affecting the security of electronic protected health information, per 45 CFR Section 164.308(a)(8).
ID TIP_HIPAAPeriodicSecurityProceduresEvaluationProfile
 TD  Assigned Security Responsibility, v1.0
Description Specifies that a health care related organization must identify the security official who is responsible for the development and implementation of the policies and procedures required by the Security Rule.
ID TD_AssignedSecurityResponsibility
Provider Reference

Terms (7)

Term Name Abbreviations Definition
Business Associate BA Covered entities engage "business associates" to work on their behalf. A business associate is a person (not part of the workforce of the covered entity) or organization that creates, receives, maintains, or transmits protected health information on behalf of the covered entity.
Covered entities must have contracts or other arrangements in place with their business associates to ensure that the business associates safeguard protected health information, and use and disclose the information only as permitted or required by the Privacy Rule.
A covered entity may be a business associate of another covered entity.
Covered Entity CE The Administrative Simplification provisions of HIPAA apply to three types of entities, which are known as "covered entities": 1) health care providers if they transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard, 2) health plans, and 3) health care clearinghouses.
A covered entity may be a business associate of another covered entity.
Disclosure Disclosure means the release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information.
Electronic Protected Health Information e-PHI Electronic protected health information means protected health information (PHI) that is transmitted by electronic means or maintained in electronic media.
Health Insurance Portability and Accountability Act of 1996 HIPAA The HIPAA law includes Administrative Simplification provisions that require adoption of national standards for electronic health care transactions and code sets, unique health identifiers, and security. Additionally, Congress recognized that advances in electronic technology could erode the privacy of health information. Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.
Protected Health Information PHI Protected health information (PHI) means "individually identifiable health information" that is transmitted by electronic means or maintained in electronic media or transmitted or maintained in any other form or medium, except it excludes individually identifiable health information:
  1. In education records covered by the Family Educational Rights and Privacy Act;
  2. In records described at 20 U.S.C. 1232g(a)(4)(B)(iv);
  3. In employment records held by a covered entity in its role as employer;
  4. Regarding a person who has been deceased for more than 50 years.
HIPAA rules protect most PHI held or transmitted by a covered entity or its business associate, in any form or medium, whether electronic, on paper, or oral. PHI is information, including demographic information, which relates to the individual's past, present, or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual. For example, PHI includes name, address, birth date, Social Security Number, a medical record, laboratory report, or hospital bill. However, reporting or aggregating data that cannot be used to individually identify a person would not be considered PHI.
U.S. Department of Health and Human Services HHS The U.S. Department of Health and Human Services' (HHS) mission is to enhance and protect the health and well-being of all Americans by providing for effective health and human services and fostering advances in medicine, public health, and social services.
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