HIPAA Laws – What is HIPAA?


Below are the administrative and physical safeguards as outlined in the Federal Register. These requirements are items that must generally be addressed internally, even if you are outsourcing your email.

Standard: ADMINISTRATIVE SAFEGUARDS Sections Implementation Specification Required or Addressable
Security Management Process 164.308(a)(1) Risk Analysis R
Risk Management R
Sanction Policy R
Information System Activity Review R
Assigned Security Responsibility 164.308(a)(2) R
Workforce Security 164.308(a)(3) Authorization and/or Supervision A
Workforce Clearance Procedures R
Termination Procedures A
Information Access Management 164.308(a)(4) Isolating Health Care Clearinghouse Function R
Access Authorization A
Access Establishment and Modification A
Security Awareness and Training 164.310(a)(5) Security Reminders A
Protection from Malicious Software A
Log-in Monitoring A
Password Management A
Security Incident Procedures 164.308(a)(6) Response and Reporting R
Contingency Plan 164.308(a)(7) Data Backup Plan R
Disaster Recovery Plan R
Emergency Mode Operation Plan R
Testing and Revision Procedure A
Applications and Data Criticality Analysis A
Evaluation 164.308(a)(8) R
Business Associates Contracts and Other Arrangement. 164.308(b)(1) Written Contract or Other Arrangement R
Standard: PHYSICAL SAFEGUARDS Sections Implementation Specification Required or Addressable
Facility Access Controls 164.310(a)(1) Contingency Operations A
Facility Security Plan A
Access Control and Validation Procedures A
Maintenance Records A
Audit Controls 164.312(b) R
Integrity 164.312(c)(1) Mechanism to Authenticate EPHI A
Workstation Use 164.310(b) R
Workstation Security 164.310(c) R
Device and Media Controls 164.310(d) Disposal R
Media Re-use R
Accountability A
Data Backup and Storage A
 

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