HIPAA Documentation Retention Profile, v1.0

Profile of a covered entity's HIPAA requirements to maintain the policies and procedures and privacy notice and their changes in written or electronic form.
Identifier https://artifacts.trustmarkinitiative.org/lib/tips/hipaa-documentation-retention-profile/1.0/
Publication Date 2017-02-17
Issuing Organization
Trustmark Support help@trustmarkinitiative.org 555-555-5555 No Mailing Address
Keywords There are no keywords.
Legal Notice This artifact is published by the Georgia Tech Research Institute (GTRI) as part of the Trustmark Initiative. This artifact and the information contained herein is provided on an "AS IS" basis, and GTRI 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, GTRI 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:

TD_DocumentationRetentionMaintainPoliciesandProcedures and TD_DocumentationRetentionMaintainCommunication and TD_DocumentationRetentionMaintainActionActivityDesignation and TD_DocumentationRetentionMeetBurdenofProof and TD_DocumentationRetentionTimePeriod

References (5)

 TD  Documentation Retention - Maintain Policies and Procedures, v1.0
Description Specifies that a health care provider organization must maintain the policies and procedures and privacy notice in written or electronic form.
ID TD_DocumentationRetentionMaintainPoliciesandProcedures
Provider Reference
 TD  Documentation Retention - Maintain Communication, v1.0
Description Specifies that a health care provider organization must maintain required written communication, or an electronic copy, as documentation.
ID TD_DocumentationRetentionMaintainCommunication
Provider Reference
 TD  Documentation Retention - Maintain Action Activity Designation, v1.0
Description Specifies that a health care provider organization must maintain a written or electronic record of any required action, activity, or designation.
ID TD_DocumentationRetentionMaintainActionActivityDesignation
Provider Reference
 TD  Documentation Retention - Meet Burden of Proof, v1.0
Description Specifies that a health care provider organization must maintain documentation sufficient to meet its burden of proof to demonstrate that all required notifications were made in the event of a data breach.
ID TD_DocumentationRetentionMeetBurdenofProof
Provider Reference
 TD  Documentation Retention - Time Period, v1.0
Description Specifies that a health care provider organization must retain the policy and procedure and privacy notice documentation for six years.
ID TD_DocumentationRetentionTimePeriod
Provider Reference

Terms (10)

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.
Correctional Institution CI Correctional institution means any penal or correctional facility, jail, reformatory, detention center, work farm, halfway house, or residential community program center operated by, or under contract to, the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, for the confinement or rehabilitation of persons charged with or convicted of a criminal offense or other persons held in lawful custody. Other persons held in lawful custody includes juvenile offenders adjudicated delinquent, aliens detained awaiting deportation, persons committed to mental institutions through the criminal justice system, witnesses, or others awaiting charges or trial.
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.
Plan Administration Functions PAF Plan administration functions means administration functions performed by the plan sponsor of a group health plan on behalf of the group health plan and excludes functions performed by the plan sponsor in connection with any other benefit or benefit plan of the plan sponsor.
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.
Summary Health Information Information, that may be individually identifiable health information, and that summarizes the claims history, claims expenses, or type of claims experienced by individuals.
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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