HIPAA Facility Access Control Policies Profile, v1.0

Profile of HIPAA Security Awareness and Training (per 45 CFR Section 164.310(a)) requirements for a covered entity or business associate to have policies to limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.
Identifier https://artifacts.trustmarkinitiative.org/lib/tips/hipaa-facility-access-control-policies-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:

TD_FacilityContingencyOperationsPolicies and TD_FacilitySecurityPlanPolicies and TD_FacilityAccessControlandValidationPolicies and TD_FacilityMaintenanceRecordsPolicies

References (4)

 TD  Facility Contingency Operations Policies, v1.0
Description Specifies that a health care related organization must have policies that allow facility access in support of restoration of lost data under the disaster recovery plan and emergency mode operations plan in the event of an emergency.
ID TD_FacilityContingencyOperationsPolicies
Provider Reference
 TD  Facility Security Plan Policies, v1.0
Description Specifies that a health care related organization must have policies to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft.
ID TD_FacilitySecurityPlanPolicies
Provider Reference
 TD  Facility Access Control and Validation Policies, v1.0
Description Specifies that a health care related organization must have policies to control and validate a person's access to facilities based on their role or function.
ID TD_FacilityAccessControlandValidationPolicies
Provider Reference
 TD  Facility Maintenance Records Policies, v1.0
Description Specifies that a health care related organization must have policies to document repairs and modifications to the physical components of a facility which are related to security.
ID TD_FacilityMaintenanceRecordsPolicies
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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