Phoenix Health Systems'
HIPAA Security Policies Templates Suite

For Healthcare Providers

Components of the HIPAA Security Policies Templates Suite:

The 54 policies in the suite are organized into four major categories – Administrative Safeguards, Physical Safeguards, Technical Safeguards, and Other Standards – corresponding to categorizations within the Security Rule. We include introductory how-to's and supplemental reference materials to purchasers of the complete suite to support adapting the policy templates to your environment. Suite components include:

I. GENERAL INFORMATION ABOUT HIPAA SECURITY AND USE OF POLICY TEMPLATES

Introduction to the HIPAA Security Policies Templates Suite
Integrating Best Practices for Information Security into Healthcare Organizational Policies & Procedures
Understanding the Implementation Specifications for Standards in the Final HIPAA Security Rule
HIPAA Security Standards/Policies Matrix
How to Use the Policy Templates
Guidelines for Establishing Organizational Security Policies

II. POLICIES ON THE STANDARDS FOR ADMINISTRATIVE SAFEGUARDS

1. Security Management Process	(Standard.) Describes processes the organization implements to prevent, detect, contain, and correct security violations relative to its ePHI.
2. Risk Analysis	Discusses what the organization should do to identify, define, and prioritize risks to the confidentiality, integrity, and availability of its ePHI. (Required Implementation Specification for the Security Management Process standard.)
3. Risk Management	Defines what the organization should do to reduce the risks to its ePHI to reasonable and appropriate levels. (Required Implementation Specification for the Security Management Process standard.)
4. Sanction Policy	Indicates actions that are to be taken against employees who do not comply with organizational security policies and procedures. (Required Implementation Specification for the Security Management Process standard.)
5. Information System Activity Review	Describes processes for regular organizational review of activity on its information systems containing ePHI. (Required Implementation Specification for the Security Management Process standard.)
6. Assigned Security Responsibility	(Standard.) Describes the requirements for the responsibilities of the Information Security Officer.
7. Workforce Security	(Standard.) Describes what the organization should do to ensure ePHI access occurs only by employees who have been appropriately authorized.
8. Authorization and/or Supervision	Identifies what the organization should do to ensure that all employees who can access its ePHI are appropriately authorized or supervised. (Required Implementation Specification for the Workforce Security standard.)
9. Workforce Clearance Procedure	Reviews what the organization should do to ensure that employee access to its ePHI is appropriate. (Addressable Implementation Specification for Workforce Security standard.)
10. Termination Procedures	Defines what the organization should do to prevent unauthorized access to its ePHI by former employees. (Addressable Implementation Specification for Workforce Security standard.)
11. Information Access Management	(Standard.) Indicates what the organization should do to ensure that only appropriate and authorized access is made to its ePHI.
12. Access Authorization	defines how the organization provides authorized access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)
13. Access Establishment and Modification	Discusses what the organization should do to establish, document, review, and modify access to its ePHI. (Addressable Implementation Specification for Information Access Management standard.)
14. Security Awareness & Training	(Standard.) Describes elements of the organizational program for regularly providing appropriate security training and awareness to its employees.
15. Security Reminders	Defines what the organization should do to provide ongoing security information and awareness to its employees. (Addressable Implementation Specification for Security Awareness & Training standard.)
16. Protection from Malicious Software	Indicates what the organization should do to provide regular training and awareness to its employees about its process for guarding against, detecting, and reporting malicious software. (Addressable Implementation Specification for Security Awareness & Training standard.)
17. Log-in Monitoring	Discusses what the organization should do to inform employees about its process for monitoring log-in attempts and reporting discrepancies. (Addressable Implementation Specification for Security Awareness & Training standard.)
18. Password Management	Describes what the organization should do to maintain an effective process for appropriately creating, changing, and safeguarding passwords. (Addressable Implementation Specification for Security Awareness & Training standard.)
19. Security Incident Procedures	(Standard.) Discusses what the organization should do to maintain a system for addressing security incidents that may impact the confidentiality, integrity, or availability of its ePHI.
20. Response and Reporting	Defines what the organization should do to be able to effectively respond to security incidents involving its ePHI. (Required Implementation Specification for Security Incident Prodedures standard.)
21. Contingency Plan	(Standard.) Identifies what the organization should do to be able to effectively respond to emergencies or disasters that impact its ePHI.
22. Data Backup Plan	Discusses organizational processes to regularly back up and securely store ePHI. (Required Implementation Specification for Contingency Plan standard.)
23. Disaster Recovery Plan	Indicates what the organization should do to create a disaster recovery plan to recover ePHI that was impacted by a disaster. (Required Implementation Specification for Contingency Plan standard.)
24. Emergency Mode Operation Plan	Discusses what the organization should do to establish a formal, documented emergency mode operations plan to enable the continuance of crucial business processes that protect the security of its ePHI during and immediately after a crisis situation. (Required Implementation Specification for Contingency Plan standard.)
25. Testing and Revision Procedure	Describes what the organization should do to conduct regular testing of its disaster recovery plan to ensure that it is up-to-date and effective. (Addressable Implementation Specification for Contingency Plan standard.)
26. Applications and Data Criticality Analysis	Reviews what the organization should do to have a formal process for defining and identifying the criticality of its information systems. (Addressable Implementation Specification for Contingency Plan standard.)
27. Evaluation	(Standard.) Describes what the organization should do to regularly conduct a technical and non-technical evaluation of its security controls and processes in order to document compliance with its own security policies and the HIPAA Security Rule.
28. Business Associate Contracts and Other Arrangements	(Standard.) Describes how to establish agreements that should exist between the organization and its various business associates that create, receive, maintain, or transmit ePHI on its behalf.

III. POLICIES ON THE STANDARDS FOR PHYSICAL SAFEGUARDS

29. Facility Access Controls	(Standard.) Describes what the organization should do to appropriately limit physical access to the information systems contained within its facilities, while ensuring that properly authorized employees can physically access such systems.
30. Contingency Operations	Identifies what the organization should do to have formal, documented procedures for allowing authorized employees to enter its facility to take necessary actions as defined in its disaster recovery and emergency mode operations plans. (Addressable Implementation Specification for Facility Access Controls standard.)
31. Facility Security Plan	Discusses what the organization should do to establish a facility security plan to protect its facilities and the equipment therein. (Addressable Implementation Specification for Facility Access Controls standard.)
32. Access Control and Validation Procedures	Discusses what the organization should do to appropriately control and validate physical access to its facilities containing information systems having ePHI or software programs that can access ePHI. (Addressable Implementation Specification for Facility Access Controls standard.)
33. Maintenance Records	Defines what the organization should do to document repairs and modifications to the physical components of its facilities related to the protection of its ePHI. (Addressable Implementation Specification for Facility Access Controls standard.)
34. Workstation Use	(Standard.) Indicates what the organization should do to appropriately protect its workstations.
35. Workstation Security	(Standard.) Reviews what the organization should do to prevent unauthorized physical access to workstations that can access ePHI while ensuring that authorized employees have appropriate access.
36. Device and Media Controls	(Standard.) Discusses what the organization should do to appropriately protect information systems and electronic media containing PHI that are moved to various organizational locations.
37. Disposal	Describes what the organization should do to appropriately dispose of information systems and electronic media containing ePHI when it is no longer needed. (Required Implementation Specification for Device and Media Controls standard.)
38. Media Re-use	Discusses what the organization should do to erase ePHI from electronic media before re-using the media. (Required Implementation Specification for Device and Media Controls standard.)
39. Accountability	Defines what the organization should do to appropriately track and log all movement of information systems and electronic media containing ePHI to various organizational locations. (Addressable Implementation Specification for Device and Media Controls standard.)
40. Data Backup and Storage	Discusses what the organization should do to backup and securely store ePHI on its information systems and electronic media. (Addressable Implementation Specification for Device and Media Controls standard.)

IV. POLICIES ON THE STANDARDS FOR TECHNICAL SAFEGUARDS

41. Access Control	(Standard.) Indicates what the organization should do to purchase and implement information systems that comply with its information access management policies.
42. Unique User Identification	Discusses what the organization should do to assign a unique identifier for each of its employees who access its ePHI for the purpose of tracking and monitoring use of informations systems. (Required Implementation Specification for Access Control standard.)
43. Emergency Access Procedure	Discusses what the organization should do to have a formal, documented emergency access procedure enabling authorized employees to obtain required ePHI during the emergency. (Required Implementation Specification for Access Control standard.)
44. Automatic Logoff	Discusses what the organization should do to develop and implement procedures for terminating users' sessions after a certain period of inactivity on systems that contain or have the ability to access ePHI. (Addressable Implementation Specification for Access Control standard.)
45. Encryption and Decryption	Discusses what the organization should do to appropriately use encryption to protect the confidentiality, integrity, and availability of its ePHI. (Addressable Implementation Specification for Access Control standard.)
46. Audit Controls	(Standard.) Discusses what the organization should do to record and examine significant activity on its information systems that contain or use ePHI.
47. Integrity	(Standard.) Defines what the organization should do to appropriately protect the integrity of its ePHI.
48. Mechanism to Authenticate Electronic Protected Health Information	Discusses what the organization should do to implement appropriate electronic mechanisms to confirm that its ePHI has not been altered or destroyed in any unauthorized manner. (Addressable Implementation Specification for Integrity standard.)
49. Person or Entity Authentication	(Standard.) Defines what the organization should do to ensure that all persons or entities seeking access to its ePHI are appropriately authenticated before access is granted.
50. Transmission Security	(Standard.) Describes what the organization should do to appropriately protect the confidentiality, integrity, and availability of the ePHI it transmits over electronic communications networks.
51. Integrity Controls	Indicates what the organization should do to maintain appropriate integrity controls that protect the confidentiality, integrity, and availability of the ePHI it transmits over electronic communications networks. (Addressable Implementation Specification for Transmission Security standard.)
52. Encryption	Defines what the organization should do to appropriately use encryption to protect the confidentiality, integrity, and availability of ePHI it transmits over electronic communications networks. (Addressable Implementation Specification for Transmission Security standard.)

V. POLICIES FOR THE OTHER STANDARDS

53. Policies and Procedures	(Standard.) Defines what the requirements are relative to establishing organizational policies and procedures.
54. Documentation	(Standard.) Discusses what the organization should do to appropriately maintain, distribute, and review the security policies and procedures it implements to comply with the HIPAA Security Rule.

VI. APPENDICES

White Papers:
- Summary Analysis: The Final Security Rule
- Conducting Effective Risk Analysis
- Key Security Questions for Healthcare Executives
Recommended Websites for Security Information
Glossary of HIPAA Security Terms