HIPAA Policy Templates for Covered Entities

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Model: Pce501

Description

A Complete Set of 56 HIPAA Policy Templates for Covered Entities, All New and Fully Updated for the HIPAA Final Rule.

Now Inculding the 2024 Update

Updated with the latest "Omnibus" Final Rule requirements, these editable Policy Templates are ready to be customized for your individual needs. Fifty-six templates are included, covering every area required by HIPAA and more. From the experts at HIPAA Group, this template collection allows Covered Entities to meet their compliance obligations with a minimum of hassle and expense.

A complete set of Policies and Procedures is mandatory for HIPAA compliance. If you are ever investigated or charged with a HIPAA violation, your Polices and Procedures are typically the first thing investigators want to see. Make sure you are ready!

This product includes...

Fifty-six (56) ready-to-edit Policy Templates.
A complete instruction and editing guide.
A helpful NOTES section with every Policy Template, with the text of the HIPAA Regulation that applies to that policy; extras like OCR and CMS Guidance; and tips from the experts at HIPAA Group.
An optional "Mobile Device Policy" Template, not mandated by HIPAA, but highly requested by customers.

Policy Templates are all in Microsoft Word format, and require editing before use. Add your own specific procedures to align policies with your unique business operations and priorities.

This product contains the following Policy Templates...


1	General HIPAA Compliance Policy	164.104 164.306 HITECH 13401	Covered Entities and Business Associates, as defined in HIPAA and HITECH, must comply with all required parts and subparts of the regulations that apply to each type of Entity.
2	Policies & Procedures General Requirement	164.306; 164.316 164.312(b)(1) 164.530(i)	Implement reasonable and appropriate P&Ps to comply with all standards, implementation specifications, or other requirements. P&P changes must be appropriately documented.
3	Documentation Policy Requirement	164.530(j)(1)(ii) 164.530(j)(1)(iii) 164.312(b)(2)(i) 164.316	Maintain all P&Ps in written (may be electronic) form. If an action, activity or assessment must be documented, maintain written (may be electronic) records of all.
4	Documentation Retention Policy Requirement	164.316 164.530(j)	Retain all required documentation for 6 years from the date of its creation or the date when it last was in effect, whichever is later.
5	Documentation Availability Policy Requirement	164.310 164.316 164.530(j)	Make documentation available to those persons responsible for implementing the Policies and/or Procedures to which the documentation pertains.
6	Documentation Updates Policy Requirement	164.310 164.316 164.530(j)	Review documentation periodically and update as needed, in response to environmental or operational changes affecting the security of PHI.
7	HHS Investigations Policy	160.308 164.310 164.312	CEs and BAs must implement policies & procedures to assure compliance with HHS investigation & recordkeeping requirements.
8	Breach Notification Policy	164.400 to 164.414	Requires CEs and BAs to comply with all Breach Notification requirements: risk analysis; determination of potential harm; notifications.
9	Assign Privacy Official Policy	164.530(a)	CEs and BA must assign an individual for all Privacy-related activities and compliance efforts; and to accept and process complaints.
10	State Law Preemption Policy	160.201 to 160.205	CEs and BAs must analyze and assess state law requirements related to data privacy & security; and HIPAA preemption impacts of state laws.
11	HIPAA Training Policy	164.530(b)	CEs and BAs must train all affected workforce members on their Policies & Procedures, as well as the basics of HIPAA, as needed.
12	PHI Uses & Disclosures Policy	164.502 to 164.514	CEs and BAs must establish methods and procedures to assure that all PHI uses & disclosures are in accord with HIPAA regs.
13	Patient Rights Policy	164.520 to 164.528	CEs (and BAs optionally) must implement policies & procedures to assure the lawful provision of Patient Rights as called for in HIPAA regs.
14	Complaints Policy	164.530(d) 164.530(a)	CEs and BAs must establish methods and procedures to assure the proper handling of, and response to, all complaints received.
15	Risk Management Process Policy Required	164.302 to 164.318	Establishes the overall Risk Management process that CEs and BAs must implement to meet Privacy & Security Rule compliance requirements.
16	Risk Analysis Required Standard	164.308(a)(1)	Conduct assessment of potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by the entity.
17	Risk Management Required Standard	164.308(a)(1)	Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with Sec. 164.306(a).
18	Sanction Policy Required Standard	164.308(a)(1)	Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the covered entity.
19	Information System Activity Review Required Standard	164.308(a)(1)	Implement procedures to regularly review information system activity: audit logs; access reports; and security incident reports; etc.
20	Assigned Security Responsibility Required Standard	164.308(a)(2)	Assign security responsibility. Identify Security Official responsible for development and implementation of required P&Ps.
21	Authorization & Supervision Policy Addressable Standard	164.308(a)(3)	Implement procedures for authorization and/or supervision of workers who work with ePHI or in locations where it might be accessed.
22	Workforce Clearance Policy Addressable Standard	164.308(a)(3)	Implement procedures to determine that the access of a workforce member to ePHI is appropriate.
23	Termination Policy Addressable Standard	164.308(a)(3)	Implement procedures for terminating access to ePHI when the employment ends or as required by (a)(3)(ii)(B) of this section.
24	Access Authorization Addressable Standard	164.308(a)(4)	Implement policies and procedures for granting access to ePHI, for workstations, transactions, programs, processes, or other mechanisms.
25	Access Establishment and Modification Addressable Standard	164.308(a)(4)	Implement P&Ps, based on Access Authorization policies, to establish, document, review, and modify user's rights of access to workstations, transactions, programs, or processes.
26	Security Reminders Addressable Standard	164.308(a)(5)	Implement periodic reminders of security and information safety best practices.
27	Protection from Malicious Software Addressable Standard	164.308(a)(5)	Implement Procedures for guarding against, detecting, and reporting malicious software.
28	Log-in Monitoring Addressable Standard	164.308(a)(5)	Implement Procedures for monitoring and reporting log-in attempts and discrepancies.
29	Password Management Addressable Standard	164.308(a)(5)	Implement Procedures for creating, changing, and safeguarding appropriate passwords.
30	Security Incident Policy Required Standard	164.308(a)(6) 164.400 to 164.414	Identify and respond to suspected or known security incidents. Mitigate harmful effects. Document security incidents and their outcomes.
31	Data Backup Policy Required Standard	164.308(a)(7)	Establish and implement procedures to create and maintain retrievable, exact copies of ePHI during unexpected negative events.
32	Disaster Recovery Policy Required Standard	164.308(a)(7)	Establish (and implement as needed) procedures to restore any loss of data.
33	Emergency Mode Operation Policy Required Standard	164.308(a)(7)	Establish (and implement as needed) procedures to enable continuation of critical business processes for protection of ePHI while operating in emergency mode.
34	Testing and Revision Policy Addressable Standard	164.308(a)(7)	Implement procedures for periodic testing and revision of contingency and emergency plans.
35	Applications and Data Criticality Analysis Addressable Standard	164.308(a)(7)	Assess the relative criticality of specific applications and data in support of other contingency plan components.
36	Evaluation Policy Required Standard	164.308(a)(8)	Perform periodic technical & nontechnical evaluations, to establish how well security P&Ps meet the requirements of this subpart.
37	Business Associates Policy Required Standard	164.308(b)(1) 164.410 164.502(e) 164.504(e)	CE’s must obtain, and BA’s must provide, written satisfactory assurances that all ePHI and PHI will be appropriately safeguarded.
38	Contingency Operations Policy Addressable Standard	164.310(a)(1-2)	Establish (and implement as needed) procedures that allow facility access to support restoration of lost data in the event of an emergency.
39	Facility Security Policy Addressable Standard	164.310(a)(1-2)	Implement P&P’s to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft.
40	Access Control and Validation Policy Addressable Standard	164.310(a)(1-2)	Implement procedures to control and validate individual access to facilities based on role or function; including visitor control, and access control for software testing and revision.
41	Maintenance Records Addressable Standard	164.310(a)(1-2)	Implement P&Ps to document repairs and changes to physical elements of a facility related to security (hardware, walls, doors, locks, etc.).
42	Workstation Use Required Standard	164.310(b-c)	Implement P&Ps that specify the proper functions, procedures, and appropriate environments of workstations that access ePHI.
43	Workstation Security Required Standard	164.310(b-c)	Implement physical safeguards for all workstations that access ePHI, to restrict access to authorized users.
44	Media Disposal & Disposition Required Standard	164.310(d)(1-2)	Implement P&Ps to address the final disposition of ePHI, and/or the hardware or electronic media on which it is stored.
45	Media Re-use Required Standard	164.310(d)(1-2)	Implement procedures for removal of ePHI from electronic media before the media are made available for re-use.
46	Hardware & Media Accountability Addressable Standard	164.310(d)(1-2)	Maintain records of the movements of hardware and electronic media, and any person responsible therefore.
47	Data Backup and Storage Addressable Standard	164.310(d)(1-2) 164.308(a)(7)	The Data Backup Plan defines what data is essential for continuity after damage or destruction of data, hardware, or software. Risk Analysis determines what to backup.
48	Unique User Identification Required Standard	164.306 164.312(a)(1-2)	Assign a unique name and/or number for identifying and tracking user identity.
49	Emergency Access Policy Required Standard	164.104 164.306 164.312(a)(1)	Establish (and implement as needed) procedures for obtaining necessary ePHI during an emergency.
50	Automatic Logoff Addressable Standard	164.306 164.312(a)(1-2)	Implement electronic procedures that terminate an electronic session after a predetermined time of inactivity.
51	Encryption and Decryption Addressable Standard	164.312(a)(1-2)	Implement an appropriate mechanism to encrypt and decrypt ePHI.
52	Audit Controls Required Standard	164.312(b)	Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI.
53	Integrity Controls Policy Addressable Standard	164.312(c)(1-2)	Implement electronic mechanisms to corroborate that ePHI has not been altered or destroyed in an unauthorized manner.
54	Person or Entity Authentication Required Standard	164.312(d)	Implement procedures to verify that a person or entity seeking access to ePHI is the one claimed.
55	Transmission Security Policy Addressable Standard	164.312(e)(1)	Implement security measures to ensure that electronically transmitted ePHI is not improperly modified without detection until disposed of.
56	Mobile Device Policy Optional Policy	164.302-164.314	Governs the use in an entity of mobile devices that can access, use, transmit, or store ePHI.