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Privacy & Security Documents

PRIVACY AND SECURITY TOPIC

DELIVERABLE(s)
Access to Protected Health Information (PHI) 164.524
  1. Patient Right to Access, Inspect and Copy Protected Health Information
  2. Minors and Access Doc
  3. Charging for Copies and Summaries
Accounting of Disclosures                                   164.528
  1. Accounting of Disclosures
Alternative Communications 164.522 (b)
  1. Individual Right to Request Alternative Communications
Amendment                                                     164.526
  1. Amendment Policy
  2. Amendment Form
  3. Sample Letters for Amendment Policy
Auditing/Activity Review

  • Audit Controls 164.312(b)
  • Information System Activity Review 164.308(a)(1)(ii)(D)
  • Log-in Monitoring 164.308(a)(5)(ii)(C)
  • Protection from Malicious Software 164.308(a)(5)(ii)(B)
  1. Information System Activity Review Policy (formerly named Auditing Policy)
Authorization 164.508
    1. Consent for Disclosure of Patient PHI
    1. Validity of Patient Authorization
    1. Authorization Elements Grid
    1. WI Authorization Form
    1. Audio, Video and Photo Consent 10.1.17
  1. Issue of Requiring Authorization Forms to include Copy or Fax – Position Statement
Breach Notification   Part 164 Subpart D

  • Sanction Policy 164.308(a)(1)(ii)(C)
  1. 2013 Omnibus Rule Version Breach Notification Policy – Compliance Date 9/23/13
  2. Privacy Officer Breach Notification Checklist
  3. ARRA/HITECH Breach Notification Policy 1-3-11
Business Associate

  • 164.308(b)
  • 164.314
  • 164.504(e)
  • HITECH Sections 13401(a), 13404, 13408
  1. BA Agreement Omnibus Rule
  2. Business Associate Policy
  3. BA Training PPT
Complaint  164.530(d)(1)
  1. Privacy Complaint Policy & Form
Contingency Plan 164.308(a)(7)

  • Contingency Operations 164.310(a)(2)(i)
  • Emergency Access Procedure 164.312(a)(2)(ii)
  1. Contingency Planning Whitepaper
Consumer Guide
  1. Wisconsin Consumer HIPAA Guide PDF
Data Management

  • Accountability 164.310(d)(2)(iii)
  • Data Backup and Storage 164.310(d)(2)(iv)
  • Data Backup Plan 164.308(a)(7)(ii)(A)
  • Device and Media Controls 164.310(d)
  1. Data Management & Backup Doc
De-Identification 164.514
  1. De-ID vs LDS
Designated Record Set  164.501
  1. Designated Record Set Doc
Device & Media Controls 164.310(d)

  • Disposal 164.310(d)(2)(i)
  • Media Re-use 164.310(d)(2)(ii)
  • Portable Handheld Devices
  • Removable Media
  1. Device, Media, & Paper Record Sanitization for Disposal or Reuse Doc
  2. Portable Handheld Device Policy
  3. Removable Media Policy
Employee Health
  1. Management of Employee Health Records Whitepaper
Facility Access Controls 164.310(a)(1)

  • Access Control & Validation Procedures 164.310(a)(2)(iii)
  • Facility Security Plan 164.310(a)(2)(ii)
  1. Facility Access Policy
Facility Maintenance Records 164.310(a)(2)(iv)
  1. Facility Maintenance & Repairs Policy Doc
Fundraising  164.514(f)(1)
  1. Fundraising Policy Doc
Group Health Plan Requirements

  • 164.314(b)
  • 164.504(f)
  1. Plan Documents Policy Doc
Information Access Management 164.308(a)(4)(i)

  • Access Control 164.312(a)(1)
  • Access Establishment and Modification 164.308(a)(4)(ii)(C)
  • Authorization and/or Supervision   164.308(a)(3)(ii)(A)
  • Automatic Logoff 164.312(a)(2)(iii)
  • Isolating Healthcare Clearinghouse Function 164.308(a)(4)(ii)(A)
  • Password Management 164.308(a)(5)(ii)(D)
  • Person or Entity Authentication 164.312(d)
  • Termination Procedures 164.308(a)(3)(ii)(C)
  • Unique User Identification 164.312(a)(2)(i)
  • Workforce Clearance Procedure   164.308(a)(3)(ii)(B)
  • Workforce Security 164.308(a)(3)(i)
  • Workstation Use 164.310(b)
  1. System Access Policy
  2. Remote Access Policy
Judicial Proceeding 164.512(e)
  1. Policy & Procedure for Use and Disclosure of PHI for Judicial and Administrative Proceedings
Law Enforcement 164.512(f)
  1. HIPAA & Wisconsin Law Enforcement
  2. Drug Seeking Behavior Whitepaper
  3. 2016 Privacy Rule Modification—Firearms Safety
  4. Use of Body Cameras by Law Enforcement
Limited Data Set  164.514
  1. De-ID vs LDS
Marketing  164.501
  1. Marketing Policy Doc
Media
  1. Disclosure of PHI to the Media
Minimum Necessary 164.514
  1. Minimum Necessary Training PPT
  2. Minimum Necessary Doc
Notice of Privacy Practice 164.520
  1. Privacy Notice Policy – Provider
  2. Model Privacy Notice – Provider
  3. Acknowledgement
  4. Privacy Notice Policy – Payer
  5. Model Privacy Notice – Payer
  6. Patient Privacy Rights – Policy
  7. Patient Privacy Rights – PowerPoint
Occupational Health
  1. Occupational Health Whitepaper 4-15-13
Policies & Procedures

  • Privacy 164.530(i)
  • Security 164.316
  1. Example Policy & Procedure Template
  2. HIPAA Security Policy and Procedure Checklist
  3. Security Standards and Associated P&Ps 
Preemption with Wisconsin Law

  • Part 160 Subpart B
  1. Preemption Analysis Supplement Definitions
  2. Preemption – WI 146 Pdf
  3. Preemption – WI 51.30 Pdf
  4. Preemption – WI 252 Pdf
  5. Preemption – WI 256.50 Doc
  6. Preemption Matrix (Payer) Doc
  7. HIPAA Harmonization Guidance WHIMA
Privacy Officer  164.530(a)
  1. HIPAA Implementation & Oversight Doc
Psychotherapy Notes  164.508(a)(2)
  1. Psychotherapy Notes
Restriction Request  164.522 (a)
  1. Individual Right to Request Restrictions on How PHI is Used/Disclosed for TPO
Risk Analysis & Management

  • 164.308 (a)(1)(ii)(A) and (B)
  • Evaluation 164.308(a)(8)
  • Meaningful Use – CMS EHR Incentive program
  • Protect Electronic Health Information Requirements
  • Safeguards – Administrative 164.306
  • Safeguards – Physical 164.310
  1. Risk Management Policy Doc
  2. Risk Toolkit Guide
  3. Risk Assessment Template
  4. Privacy, Security, & Meaningful Use Questions to Ask Vendors Doc
Safeguards  164.530 (c)
  1. Communication of PHI Policy Doc
Security Incident Procedures 164.308(a)(6)

  • Security Management Process 164.308(a)(1)(i)
  1. Security Incident Response Doc

Also Refer to Breach Notification Section
Security Oversight:

  • General Rules 164.306
  • Policies & Procedures & Documentation Requirements 164.316
  • Security Awareness and Training 164.308(a)(5)(i)
  • Security Reminders 164.308(a)5)(ii)(A)
  • Sanction Policy 164.308(a)(1)(ii)(C)
  1. HIPAA Security Oversight Policy
  2. Security Benchmarking Whitepaper

Also Refer to Training Section
Social Media
  1. Social Media Guidelines
Technical Access Control:

  • Encryption 164.312(e)(2)(ii)
  • Encryption and Decryption 164.312(a)(2)(iv)
  • Integrity 164.312(c)
  • Integrity Controls 164.312(e)(2)(i)
  • Transmission Security 164.312(e)(1)
  1. Encryption Whitepaper
Training

  • 164.530(b)(1)
  • 164.308(a)(5)
  1. Privacy & Security Training Session PowerPoint

Also Refer to Security Oversight Section
Treatment Uses and Disclosures  164.506
  1. Position Statement: Disclosing PHI for Treatment Purposes Doc
Verification of Identity 164.514(h)
  1. Identity Verification
Workers Compensation  164.512(l)
  1. Workers Compensation