Chris Bennington, Esq., INCompliance Consulting Shannon DeBra, Esq., Bricker & Eckler LLP Victoria Norton, R.N., J.D., M.B.A.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Chris Bennington, Esq., INCompliance Consulting Shannon DeBra, Esq., Bricker & Eckler LLP Victoria Norton, R.N., J.D., M.B.A."

Transcription

1 Chris Bennington, Esq., INCompliance Consulting Shannon DeBra, Esq., Bricker & Eckler LLP Victoria Norton, R.N., J.D., M.B.A., UC Health v1 Examples from the News Review of HIPAA Breach Regulations Walk-Through of an Actual HIPAA Crisis Strategies and Lessons Learned Q&A 2 1

2 3 4 2

3 5 A breach is an impermissible use or disclosure of PHI that compromises the security or privacy of the PHI. Under Omnibus Final Rule, a use or disclosure of PHI in a manner not permitted under the Rules is now presumed to be a breach. 6 3

4 Unintentional acquisition, access, or use of PHI by a workforce member, if such acquisition, access, or use was made in good faith and within the scope of authority. Inadvertent disclosure of PHI by a person authorized to access PHI at a covered entity or business associate to another person authorized to access PHI at the covered entity or business associate. Impermissible disclosure, but the covered entity has a good faith belief that the unauthorized person to whom the disclosure was made would not have been able to retain the information. 7 Not all breaches are reportable. If a breach is reportable, a Covered Entity must notify the patient and HHS of the breach. If the breach involved 500 or more patients, the Covered Entity must also notify local media. 8 4

5 Covered entities and business associates must only provide the required notifications if the breach involved unsecured PHI. Unsecured PHI is PHI that has not been rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by HHS. A breach of secured PHI is not reportable. 9 A breach of unsecured PHI is not reportable if the covered entity demonstrates that there is a low probability that the PHI has been compromised based on a risk assessment including at least the four factors established by HHS. 10 5

6 1) The nature and extent of the PHI involved, including the types of identifiers and the likelihood of reidentification; 2) The unauthorized person who used the PHI or to whom the disclosure was made; 3) Whether the PHI was actually acquired or viewed; and 4) The extent to which the risk to the PHI has been mitigated. 11 Fewer than 500 Affected Individuals 500 or More Affected Individuals Individual Notice Within 60 Days of Discovery Within 60 Days of Discovery Media Notice N/A Within 60 Days of Discovery HHS Notice Within 60 Days of the End of the Calendar Year of Discovery Within 60 Days of Discovery 12 6

7 Dear We are writing to notify you that some of your health information maintained by [Insert Name of Organization] has been improperly disclosed or accessed. [Insert Name of Organization] is committed to maintaining health information in a secure and confidential manner in accordance with federal and state law, and we regret that these standards were not met in this instance. What happened. We believe the breach of your health information occurred on [Insert date of breach]. On that date [Insert a brief description of what happened]. We discovered that this breach occurred on [Insert date of discovery of breach]. 13 What information was breached. The information that was breached was your [Insert a brief description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, or disability code)]. What should you do. We believe that you may wish to take the following actions to help protect yourself from potential effects of this breach: [Insert recommended mitigating steps]. 14 7

8 What we are doing. We are taking this incident very seriously. We are conducting an investigation into how this occurred. We are taking steps to prevent any further breaches of health information. Further, we are: [Insert mitigation actions]. Finally, we will be notifying the HHS of this incident Who you can contact for more information. If you have any questions or desire additional information you may contact [Insert name of person to contact] at [Insert at least one of the following for the contact: (1) toll-free telephone number, (2) an address, (3) website, or (4) postal address]. Sincerely, [Name and Title] 15 Required Notifications Employee Disciplinary Action Professional Reputation/Licensure Organizational Reputation Government Investigation Government Corrective Actions/Fines Substantial Financial and Time Expense 16 8

9 HHS investigates and imposes fines/corrective action for self-reported breaches. HHS also learns of breaches through complaints, which may be filed by anyone. Fines vary; up to $1.5 million per year. Associated costs can surpass $15 million. Patients affected will soon receive part of the fine/settlement (Regulations forthcoming)

10 Individual alleged that employees of UCMC accessed her electronic protected health information and posted a screen shot of her electronic medical record to a Facebook group called Team No Hoes. According to the reports, the screen shot was also disseminated in an that was sent to the approximately 2,200 members of the Facebook group Reports indicated the PHI depicted in the screen shot allegedly included her name and information about her syphilis diagnosis. Story picked up by multiple TV channels and local newspaper

11 Complaint Received Within a week - Response team formed Within a week- Investigation Completed Shortly after Breach Notification to HHS 21 Compliance Privacy/Security Officer(s) Legal IT/Medical Records Human Resources Public Relations Patient Relations Risk Management Quality/Safety Contract Management (if BA) 11

12 June 5, Media coverage of lawsuit filed June 5, 2014 OCR became aware of news reports July 25, 2014 OCR sent notification letter to Privacy Officer of opened compliance review Response due within 21 days

13 Carefully craft media notice Ensure Public Relations staff are aware of potential for media inquiries Prepare responses to likely questions in advance Distribute talking points to other stakeholders Avoid additional breaches in media responses Detailed description of the event Risk analysis report Evidence of security measures Evidence of sanction policies and procedures Evidence of authorization and/or supervision of workforce members who work with ephi Evidence that workforce access to ephi is appropriate 26 13

14 Evidence of workforce security awareness training Copy of policies and procedures to address security incidents Copy of incident report in response to the theft and any correction actions taken Documentation that organization had implemented mechanisms that record and examine activity information systems and an audit of the medical record at issue Copy of the letter sent to the affected individual Copy of the Breach Notification to the Secretary Copy of policies and procedures related to the permissible use and disclosure and documentation that there are processes in place to prevent the impermissible uses and disclosures Documentation of training Evidence of mitigation 28 14

15 Data request submitted Additional information requested and sent by encrypted Additional information sent via certified mail 29 Detailed position statement Policies and procedures Training Evidence of mitigation Breach notification letter Notification to Secretary 15

16 Be proactive Get familiar with your EMR and all the ways data can be accessed keep in mind that the traditional audit trail function may not show all accesses Manage the message Clearly define roles and responsibilities Document, Document, Document! 32 16

BREACH NOTIFICATION POLICY

BREACH NOTIFICATION POLICY PRIVACY 2.0 BREACH NOTIFICATION POLICY Scope: All subsidiaries of Universal Health Services, Inc., including facilities and UHS of Delaware Inc. (collectively, UHS ), including UHS covered entities ( Facilities

More information

STANDARD ADMINISTRATIVE PROCEDURE

STANDARD ADMINISTRATIVE PROCEDURE STANDARD ADMINISTRATIVE PROCEDURE 16.99.99.M0.26 Investigation and Response to Breach of Unsecured Protected Health Information (HITECH) Approved October 27, 2014 Next scheduled review: October 27, 2019

More information

This presentation focuses on the Healthcare Breach Notification Rule. First published in 2009, the final breach notification rule was finalized in

This presentation focuses on the Healthcare Breach Notification Rule. First published in 2009, the final breach notification rule was finalized in This presentation focuses on the Healthcare Breach Notification Rule. First published in 2009, the final breach notification rule was finalized in the HIPAA Omnibus Rule of 2013. As part of the American

More information

ADMINISTRATIVE REGULATION EFFECTIVE DATE: 1/1/2016

ADMINISTRATIVE REGULATION EFFECTIVE DATE: 1/1/2016 Page 1 of 9 CITY OF CHESAPEAKE, VIRGINIA NUMBER: 2.62 ADMINISTRATIVE REGULATION EFFECTIVE DATE: 1/1/2016 SUPERCEDES: N/A SUBJECT: HUMAN RESOURCES DEPARTMENT CITY OF CHESAPEAKE EMPLOYEE/RETIREE GROUP HEALTH

More information

UNIVERSITY OF WYOMING HIPAA POLICY 3.6 BREACH

UNIVERSITY OF WYOMING HIPAA POLICY 3.6 BREACH UNIVERSITY OF WYOMING HIPAA POLICY 3.6 BREACH I. PURPOSE: The purpose of this policy is to outline the processes and procedures for determining whether the security or privacy of PHI has been compromised

More information

Anatomy of a Health Care Data Breach (a.k.a. Breaches, Breaches, and More Breaches)

Anatomy of a Health Care Data Breach (a.k.a. Breaches, Breaches, and More Breaches) Anatomy of a Health Care Data Breach (a.k.a. Breaches, Breaches, and More Breaches) Presented by: Allyson Jones Labban, Esq. 300 N. Greene Street, Ste. 1400 Greensboro, NC 27401 T: 336.378.5200 E: allyson.labban@smithmoorelaw.com

More information

COMPLIANCE ALERT 10-12

COMPLIANCE ALERT 10-12 HAWAII HEALTH SYSTEMS C O R P O R A T I O N "Touching Lives Every Day COMPLIANCE ALERT 10-12 HIPAA Expansion under the American Recovery and Reinvestment Act of 2009 The American Recovery and Reinvestment

More information

POLICY AND PROCEDURE MANUAL

POLICY AND PROCEDURE MANUAL Pennington Biomedical POLICY NO. 412.22 POLICY AND PROCEDURE MANUAL Origin Date: 02/04/2013 Impacts: ALL PERSONNEL Effective Date: 03/17/2014 Subject: HIPAA BREACH NOTIFICATION Last Revised: Source: LEGAL

More information

The ReHabilitation Center. 1439 Buffalo Street. Olean. NY. 14760

The ReHabilitation Center. 1439 Buffalo Street. Olean. NY. 14760 Procedure Name: HITECH Breach Notification The ReHabilitation Center 1439 Buffalo Street. Olean. NY. 14760 Purpose To amend The ReHabilitation Center s HIPAA Policy and Procedure to include mandatory breach

More information

QUEST, INC BREACH NOTIFICATION POLICY

QUEST, INC BREACH NOTIFICATION POLICY QUEST, INC BREACH NOTIFICATION POLICY Dev September 2012 Page Number I. Breach Notification Template HIPAA Breach Notification Policy Table of Contents 1 A. Generally 1 B. When a Breach is Considered to

More information

Responding to HIPAA Breaches

Responding to HIPAA Breaches Responding to HIPAA Breaches 11/06/2015 by Kim Stanger HIPAA privacy and security breaches can result in fines of $100 to $50,000 to covered entities (including healthcare providers and health plans) and

More information

3.) The Breach Notification Rule (Part 164, Subpart D)

3.) The Breach Notification Rule (Part 164, Subpart D) 3.) The Breach Notification Rule (Part 164, Subpart D) 164.400 Applicability 164.402 Definitions (breach, unsecured protected health information) 164.404 Notification to individuals 164.406 Notification

More information

Information Privacy and Security Program. Title: EC.PS.01.02

Information Privacy and Security Program. Title: EC.PS.01.02 Page: 1 of 9 I. PURPOSE: The purpose of this standard is to ensure that affected individuals, the media, and the Secretary of Health and Human Services (HHS) are appropriately notified of any Breach of

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Data Breach Notification Policy 10240

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Data Breach Notification Policy 10240 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy - Data Breach Notification Policy 10240 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance

More information

What You Need to Know About the New HIPAA Breach Notification Rule 1

What You Need to Know About the New HIPAA Breach Notification Rule 1 What You Need to Know About the New HIPAA Breach Notification Rule 1 New regulations effective September 23, 2009 require all physicians who are covered by HIPAA to notify patients if there are breaches

More information

UNDERSTANDING THE HIPAA/HITECH BREACH NOTIFICATION RULE 2/25/14

UNDERSTANDING THE HIPAA/HITECH BREACH NOTIFICATION RULE 2/25/14 UNDERSTANDING THE HIPAA/HITECH BREACH NOTIFICATION RULE 2/25/14 RULES Issued August 19, 2009 Requires Covered Entities to notify individuals of a breach as well as HHS without reasonable delay or within

More information

HIPAA AND MEDICAID COMPLIANCE POLICIES AND PROCEDURES

HIPAA AND MEDICAID COMPLIANCE POLICIES AND PROCEDURES SALISH BHO HIPAA AND MEDICAID COMPLIANCE POLICIES AND PROCEDURES Policy Name: HIPAA BREACH NOTIFICATION REQUIREMENTS Policy Number: 5.16 Reference: 45 CFR Parts 164 Effective Date: 03/2016 Revision Date(s):

More information

BREACH NOTIFICATION FOR UNSECURED PROTECTED HEALTH INFORMATION

BREACH NOTIFICATION FOR UNSECURED PROTECTED HEALTH INFORMATION BREACH NOTIFICATION FOR UNSECURED PROTECTED HEALTH INFORMATION Summary November 2009 On August 24, 2009, the Department of Health and Human Services (HHS) published an interim final rule (the Rule ) that

More information

University of Wisconsin-Madison Policy and Procedure

University of Wisconsin-Madison Policy and Procedure Page 1 of 12 I. Policy The Health Information Technology for Economic and Clinical Health Act ( HITECH ) regulations contain requirements for notifying individuals in the event of a breach of their unsecured

More information

New HIPAA Breach Notification Rule: Know Your Responsibilities. Loudoun Medical Group Spring 2010

New HIPAA Breach Notification Rule: Know Your Responsibilities. Loudoun Medical Group Spring 2010 New HIPAA Breach Notification Rule: Know Your Responsibilities Loudoun Medical Group Spring 2010 Health Information Technology for Economic and Clinical Health Act (HITECH) As part of the Recovery Act,

More information

Business Associates and Breach Reporting Under HITECH and the Omnibus Final HIPAA Rule

Business Associates and Breach Reporting Under HITECH and the Omnibus Final HIPAA Rule Business Associates and Breach Reporting Under HITECH and the Omnibus Final HIPAA Rule Patricia D. King, Esq. Associate General Counsel Swedish Covenant Hospital Chicago, IL I. Business Associates under

More information

Barnes & Thornburg LLP HIPAA Update: HITECH Act Breach Notification Rule

Barnes & Thornburg LLP HIPAA Update: HITECH Act Breach Notification Rule HEALTHCARE October 2009 Barnes & Thornburg LLP HIPAA Update: HITECH Act Breach Notification Rule This HIPAA Update provides a detailed description of the new breach notification requirements for HIPAA

More information

Breach Notification Decision Process 1/1/2014

Breach Notification Decision Process 1/1/2014 WEDI Strategic National Implementation Process (SNIP) Privacy and Security Workgroup Breach Risk Assessment Issue Brief Breach Notification Decision Process 1/1/2014 Workgroup for Electronic Data Interchange

More information

HIPAA Update Focus on Breach Prevention

HIPAA Update Focus on Breach Prevention HIPAA Update Focus on Breach Prevention Objectives By the end of this program, participants should be able to: Identify top reasons why breaches occur Review the breach definition and notification process

More information

LIVINGSTON COUNTY ADMINISTRATIVE PROCEDURE HIPAA-4. Breach Notification for Unsecured Protected Health Information

LIVINGSTON COUNTY ADMINISTRATIVE PROCEDURE HIPAA-4. Breach Notification for Unsecured Protected Health Information LIVINGSTON COUNTY ADMINISTRATIVE PROCEDURE HIPAA-4 SUBJECT: ORGANIZATION RESPONSIBLE: Breach Notification for Unsecured Protected Health Information Information Technology Security Manager Office of Information

More information

Georgia Regional Academic Community Health Information Exchange (GRAChIE) Breach Notification Policy Effective Date: May, 2012 Revision Date: New

Georgia Regional Academic Community Health Information Exchange (GRAChIE) Breach Notification Policy Effective Date: May, 2012 Revision Date: New Objective The objective of this policy is to provide guidance for breach notification by Georgia Regional Academic Community Health Information Exchange (hereafter referred to as GRAChIE) when unauthorized

More information

Community First Health Plans Breach Notification for Unsecured PHI

Community First Health Plans Breach Notification for Unsecured PHI Community First Health Plans Breach Notification for Unsecured PHI The presentation is for informational purposes only. It is the responsibility of the Business Associate to ensure awareness and compliance

More information

Reporting of Security Breach of Protected Health Information including Personal Health Information 3364-100-90-15 Hospital Administration

Reporting of Security Breach of Protected Health Information including Personal Health Information 3364-100-90-15 Hospital Administration Name of Policy: Policy Number: Department: Reporting of Security Breach of Protected Health Information including Personal Health Information 3364-100-90-15 Hospital Administration Approving Officer: Interim

More information

Five Rivers Medical Center, Inc. 2801 Medical Center Drive Pocahontas, AR 72455. Notification of Security Breach Policy

Five Rivers Medical Center, Inc. 2801 Medical Center Drive Pocahontas, AR 72455. Notification of Security Breach Policy Five Rivers Medical Center, Inc. 2801 Medical Center Drive Pocahontas, AR 72455 Notification of Security Breach Policy Purpose: This policy has been adopted for the purpose of complying with the Health

More information

HHS Issues Rule Requiring Individuals Be Notified of Breaches of Their Health Information

HHS Issues Rule Requiring Individuals Be Notified of Breaches of Their Health Information HHS Issues Rule Requiring Individuals Be Notified of Breaches of Their Health Information New regulations requiring health care professionals, health plans, and other entities covered by the Health Insurance

More information

POLICY NAME: NOTICE OF PRIVACY BREACHES

POLICY NAME: NOTICE OF PRIVACY BREACHES NOTE: This sample policy is drafted to comply with the HIPAA breach notification rules as amended January 2013. The user should review applicable laws and regulations and modify this sample policy as appropriate

More information

CMA BUSINESS ASSOCIATE AGREEMENT WITH CMA MEMBERS

CMA BUSINESS ASSOCIATE AGREEMENT WITH CMA MEMBERS CMA BUSINESS ASSOCIATE AGREEMENT WITH CMA MEMBERS Dear Physician Member: Thank you for contacting the California Medical Association and thank you for your membership. In order to advocate on your behalf,

More information

Everett School Employee Benefit Trust. Reportable Breach Notification Policy HIPAA HITECH Rules and Washington State Law

Everett School Employee Benefit Trust. Reportable Breach Notification Policy HIPAA HITECH Rules and Washington State Law Everett School Employee Benefit Trust Reportable Breach Notification Policy HIPAA HITECH Rules and Washington State Law Introduction The Everett School Employee Benefit Trust ( Trust ) adopts this policy

More information

HIPAA 101. March 18, 2015 Webinar

HIPAA 101. March 18, 2015 Webinar HIPAA 101 March 18, 2015 Webinar Agenda Acronyms to Know HIPAA Basics What is HIPAA and to whom does it apply? What is protected by HIPAA? Privacy Rule Security Rule HITECH Basics Breaches and Responses

More information

FEDERAL AND STATE BREACH NOTIFICATION LAWS FOR CALIFORNIA

FEDERAL AND STATE BREACH NOTIFICATION LAWS FOR CALIFORNIA APPENDIX PR 12-A FEDERAL AND STATE BREACH NOTIFICATION LAWS FOR CALIFORNIA LEGAL CITATION California Civil Code Section 1798.82 California Health and Safety (H&S) Code Section 1280.15 42 U.S.C. Section

More information

Updated HIPAA Regulations What Optometrists Need to Know Now. HIPAA Overview

Updated HIPAA Regulations What Optometrists Need to Know Now. HIPAA Overview Updated HIPAA Regulations What Optometrists Need to Know Now The U.S. Department of Health & Human Services Office for Civil Rights recently released updated regulations regarding the Health Insurance

More information

HIPAA Privacy Breach Notification Regulations

HIPAA Privacy Breach Notification Regulations Technical Bulletin Issue 8 2009 HIPAA Privacy Breach Notification Regulations On August 24, 2009 Health and Human Services (HHS) issued interim final regulations implementing the HIPAA Privacy Breach Notification

More information

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist

HIPAA Omnibus Rule Overview. Presented by: Crystal Stanton MicroMD Marketing Communication Specialist HIPAA Omnibus Rule Overview Presented by: Crystal Stanton MicroMD Marketing Communication Specialist 1 HIPAA Omnibus Rule - Agenda History of the Omnibus Rule What is the HIPAA Omnibus Rule and its various

More information

NCHICA HITECH Act Breach Notification Risk Assessment Tool. Prepared by the NCHICA Privacy, Security & Legal Officials Workgroup

NCHICA HITECH Act Breach Notification Risk Assessment Tool. Prepared by the NCHICA Privacy, Security & Legal Officials Workgroup NCHICA HITECH Act Breach Notification Risk Assessment Tool Prepared by the NCHICA Privacy, Security & Legal Officials Workgroup NORTH CAROLINA HEALTHCARE INFORMATION AND COMMUNICATIONS ALLIANCE, INC August

More information

BREACH MANAGEMENT & NOTIFICATION POLICY

BREACH MANAGEMENT & NOTIFICATION POLICY PURPOSE To ensure that the impermissible or unauthorized use or disclosure of an Individual s Protected Health Information (PHI) will be reported and Participants shall comply with the notification requirements

More information

NEW JERSEY DATA BREACH NOTIFICATION & IDENTITY THEFT PREVENTION POLICY **DISCLAIMER**

NEW JERSEY DATA BREACH NOTIFICATION & IDENTITY THEFT PREVENTION POLICY **DISCLAIMER** NEW JERSEY DATA BREACH NOTIFICATION & IDENTITY THEFT PREVENTION POLICY **DISCLAIMER** This document was prepared to assist the typical physician practice in seeking to undertake reasonable measures to

More information

Definitions: 45 CFR As used in this subpart, the following terms have the following meanings:

Definitions: 45 CFR As used in this subpart, the following terms have the following meanings: HITECH/HIPAA Breach Notification Regulations This summary was prepared by the New Jersey Department of Human Services Privacy Officer on February 24, 2010 for distribution at the Division of Addiction

More information

FIVE EASY STEPS FOR HANDLING NEW HIPAA REQUIREMENTS & MANAGING YOUR ELECTRONIC COMMUNICATIONS

FIVE EASY STEPS FOR HANDLING NEW HIPAA REQUIREMENTS & MANAGING YOUR ELECTRONIC COMMUNICATIONS FIVE EASY STEPS FOR HANDLING NEW HIPAA REQUIREMENTS & MANAGING YOUR ELECTRONIC COMMUNICATIONS James J. Eischen, Jr., Esq. October 2013 Chicago, Illinois JAMES J. EISCHEN, JR., ESQ. Partner at Higgs, Fletcher

More information

HIPPA and HITECH NOTIFICATION Effective Date: September 23, 2013

HIPPA and HITECH NOTIFICATION Effective Date: September 23, 2013 HIPPA and HITECH NOTIFICATION Effective Date: September 23, 2013 Orchard Creek Health Care is required by law to maintain the privacy of protected health information (PHI) of our residents. If you feel

More information

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing

HIPAA Omnibus Rule Practice Impact. Kristen Heffernan MicroMD Director of Prod Mgt and Marketing HIPAA Omnibus Rule Practice Impact Kristen Heffernan MicroMD Director of Prod Mgt and Marketing 1 HIPAA Omnibus Rule Agenda History of the Rule HIPAA Stats Rule Overview Use of Personal Health Information

More information

HIPAA Data Breaches: Managing Them Internally and in Response to Civil/Criminal Investigations

HIPAA Data Breaches: Managing Them Internally and in Response to Civil/Criminal Investigations HIPAA Data Breaches: Managing Them Internally and in Response to Civil/Criminal Investigations Health Care Litigation Webinar Series March 22, 2012 Spence Pryor Paula Stannard Jason Popp 1 HIPAA/HITECH

More information

SALT LAKE COUNTY COUNTYWIDE POLICY ON HIPAA BREACH NOTIFICATION REQUIREMENTS

SALT LAKE COUNTY COUNTYWIDE POLICY ON HIPAA BREACH NOTIFICATION REQUIREMENTS SALT LAKE COUNTY COUNTYWIDE POLICY ON HIPAA BREACH NOTIFICATION REQUIREMENTS Reference Purpose Health Insurance Portability and Accountability Act of 1996 (HIPAA); 45 United States Code 1320d et seq.;

More information

My Docs Online HIPAA Compliance

My Docs Online HIPAA Compliance My Docs Online HIPAA Compliance Updated 10/02/2013 Using My Docs Online in a HIPAA compliant fashion depends on following proper usage guidelines, which can vary based on a particular use, but have several

More information

11/5/2014 PRESENTER HIPAA OBJECTIVES PROTECTED HEALTH INFORMATION BREACH DEFINITION

11/5/2014 PRESENTER HIPAA OBJECTIVES PROTECTED HEALTH INFORMATION BREACH DEFINITION PRESENTER HIPAA BREACH: It s not a Matter of If, but WHEN Chrisann Lemery, MSE, RHIA, CHPS, FAHIMA Senior Health Solutions Consultant & Privacy Officer clemery@avastonetech.com Telephone: 608 449 7207

More information

Breach Notification Policy

Breach Notification Policy 1. Breach Notification Team. Breach Notification Policy Ferris State University ( Ferris State ), a hybrid entity with health care components, has established a Breach Notification Team, which consists

More information

HIPAA Update. Bob Radecki W.J. Flynn and Associates, LLC

HIPAA Update. Bob Radecki W.J. Flynn and Associates, LLC HIPAA Update Bob Radecki W.J. Flynn and Associates, LLC Background ARRA American Recovery and Reinvestment Act of 2009 HITECH Health Information Technology for Economic and Clinical Act (Title XII, Part

More information

OCR UPDATE Breach Notification Rule & Business Associates (BA)

OCR UPDATE Breach Notification Rule & Business Associates (BA) OCR UPDATE Breach Notification Rule & Business Associates (BA) Alicia Galan Supervisory Equal Opportunity Specialist March 7, 2014 HITECH OMNIBUS A Reminder of What s Included: Final Modifications of the

More information

Breach Notification and Enforcement Update

Breach Notification and Enforcement Update Breach Notification and Enforcement Update Presented to the Seattle Western Pension & Benefits Council June 16, 2015 Sarah Brown Investigator U.S. Department of Health and Human Services Office for Civil

More information

HIPAA Breach Reporting Tips & Tricks IADDA Annual Conference 2014

HIPAA Breach Reporting Tips & Tricks IADDA Annual Conference 2014 HIPAA Breach Reporting Tips & Tricks IADDA Annual Conference 2014 9/3/14 Gerald Jud E. DeLoss Disclaimer 2 o This presentation and its materials are for informational purposes only and not for the purpose

More information

12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule

12/19/2014. HIPAA More Important Than You Realize. Administrative Simplification Privacy Rule Security Rule HIPAA More Important Than You Realize J. Ira Bedenbaugh Consulting Shareholder February 20, 2015 This material was used by Elliott Davis Decosimo during an oral presentation; it is not a complete record

More information

OCR s Anatomy: HIPAA Breaches, Investigations, and Enforcement

OCR s Anatomy: HIPAA Breaches, Investigations, and Enforcement OCR s Anatomy: HIPAA Breaches, Investigations, and Enforcement Clinton Mikel The Health Law Partners, P.C. Alessandra Swanson U.S. Department of Health and Human Services - Office for Civil Rights Disclosure

More information

Iowa Health Information Network (IHIN) Security Incident Response Plan

Iowa Health Information Network (IHIN) Security Incident Response Plan Iowa Health Information Network (IHIN) Security Incident Response Plan I. Scope This plan identifies the responsible parties and action steps to be taken in response to Security Incidents. IHIN Security

More information

HHS Finalizes HIPAA Privacy and Data Security Rules, Including Stricter Rules for Breaches of Unsecured PHI

HHS Finalizes HIPAA Privacy and Data Security Rules, Including Stricter Rules for Breaches of Unsecured PHI January 23, 2013 HHS Finalizes HIPAA Privacy and Data Security Rules, Including Stricter Rules for Breaches of Unsecured PHI Executive Summary HHS has issued final regulations that address recent legislative

More information

NOTICE OF THE NATHAN ADELSON HOSPICE PRIVACY PRACTICES

NOTICE OF THE NATHAN ADELSON HOSPICE PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY. DEFINITIONS PROTECTED HEALTH INFORMATION (PHI):

More information

Violation Become a Privacy Breach? Agenda

Violation Become a Privacy Breach? Agenda How Does a HIPAA Violation Become a Privacy Breach? Karen Voiles, MBA, CHC, CHPC, CHRC Senior Managing Consultant, Compliance Agenda Differentiating between HIPAA violation and reportable breach Best practices

More information

INFORMATION SECURITY & HIPAA COMPLIANCE MPCA

INFORMATION SECURITY & HIPAA COMPLIANCE MPCA INFORMATION SECURITY & HIPAA COMPLIANCE MPCA Annual Conference August 5, 201 Agenda 1 HIPAA 2 The New Healthcare Paradigm Internal Compliance 4 Conclusion 2 1 HIPAA 1 Earning Their Trust 4 HIPAA 5 Health

More information

M E M O R A N D U M. Definitions

M E M O R A N D U M. Definitions M E M O R A N D U M DATE: November 10, 2011 TO: FROM: RE: Krevolin & Horst, LLC HIPAA Obligations of Business Associates In connection with the launch of your hosted application service focused on practice

More information

SCHOOL DISTRICT OF BLACK RIVER FALLS HIPAA PRIVACY AND SECURITY POLICY

SCHOOL DISTRICT OF BLACK RIVER FALLS HIPAA PRIVACY AND SECURITY POLICY SCHOOL DISTRICT OF BLACK RIVER FALLS HIPAA PRIVACY AND SECURITY POLICY 1 School Board Policy 523.5 The School District of Black River Falls ( District ) is committed to compliance with the health information

More information

What do you need to know?

What do you need to know? What do you need to know? DISCLAIMER Please note that the information provided is to inform our clients and friends of recent HIPAA and HITECH act developments. It is not intended, nor should it be used,

More information

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com

Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com Heather L. Hughes, J.D. HIPAA Privacy Officer U.S. Legal Support, Inc. hhughes@uslegalsupport.com www.uslegalsupport.com HIPAA Privacy Rule Sets standards for confidentiality and privacy of individually

More information

Healthcare Practice. Breach Notification Requirements Under HIPAA/HITECH Act and Oregon Consumer Identity Theft Protection Act. Oregon.

Healthcare Practice. Breach Notification Requirements Under HIPAA/HITECH Act and Oregon Consumer Identity Theft Protection Act. Oregon. Healthcare Practice Breach Notification Requirements Under HIPAA/HITECH Act and Consumer Identity Theft Protection Act August 2013 Anchorage Beijing New York Portland Seattle Washington, D.C. www.gsblaw.com

More information

HIPAA OMNIBUS RULE: EXPANDED COMPLIANCE REQUIREMENTS

HIPAA OMNIBUS RULE: EXPANDED COMPLIANCE REQUIREMENTS HIPAA OMNIBUS RULE: EXPANDED COMPLIANCE REQUIREMENTS James J. Eischen, Jr., Esq. November 2013 San Diego, California JAMES J. EISCHEN, JR., ESQ. Partner at Higgs, Fletcher & Mack, LLP 26+ years of experience

More information

HIPAA Compliance: Are you prepared for the new regulatory changes?

HIPAA Compliance: Are you prepared for the new regulatory changes? HIPAA Compliance: Are you prepared for the new regulatory changes? Baker Tilly CARIS Innovation, Inc. April 30, 2013 Baker Tilly refers to Baker Tilly Virchow Krause, LLP, an independently owned and managed

More information

Trust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits

Trust 9/10/2015. Why Does Privacy and Security Matter? Who Must Comply with HIPAA Rules? HIPAA Breaches, Security Risk Analysis, and Audits HIPAA Breaches, Security Risk Analysis, and Audits Derrick Hill Senior Health IT Advisor Kentucky REC Why Does Privacy and Security Matter? Trust Who Must Comply with HIPAA Rules? Covered Entities (CE)

More information

Health Information Technology for Economic and Clinical Health Act ( HITECH ), part of the American Recovery and Reinvestment Act of 2009 ( ARRA ).

Health Information Technology for Economic and Clinical Health Act ( HITECH ), part of the American Recovery and Reinvestment Act of 2009 ( ARRA ). Client Advisory Health Care/Technology August 31, 2009 HHS Issues Security Breach Notice Rule On August 24, the Department of Health and Human Services ( HHS ) published its rule (the Rule ) implementing

More information

HIPAA BREACH NOTIFICATION REQUIREMENTS. Heman A. Marshall, III July 25, 2014

HIPAA BREACH NOTIFICATION REQUIREMENTS. Heman A. Marshall, III July 25, 2014 1 HIPAA BREACH NOTIFICATION REQUIREMENTS Heman A. Marshall, III July 25, 2014 2 SCENARIO FOR VBA SUMMER MEETING The Medical Marijuana Growers Association (MMGA) Health Plan, which is a self-fund plan,

More information

Implementation Business Associates and Breach Notification

Implementation Business Associates and Breach Notification Implementation Business Associates and Breach Notification Tony Brooks, CISA, CRISC, Tony.Brooks@horne-llp.com Clay J. Countryman, Esq., Clay.Countryman@bswllp.com Stephen M. Angelette, Esq., Stephen.Angelette@bswllp.com

More information

Under Attack: 10 Steps to Take If You Have a Data Breach

Under Attack: 10 Steps to Take If You Have a Data Breach Under Attack: 10 Steps to Take If You Have a Data Breach Gina Ginn Greenwood Monarch Plaza, Suite 1600 3414 Peachtree Road, N.E. Atlanta, GA 30326 Direct: 404.589.0009 Cell: 404.909.0665 ggreenwood@bakerdonelson.com

More information

SaaS. Business Associate Agreement

SaaS. Business Associate Agreement SaaS Business Associate Agreement This Business Associate Agreement ( BA Agreement ) becomes effective pursuant to the terms of Section 5 of the End User Service Agreement ( EUSA ) between Customer ( Covered

More information

HIPAA Privacy and Security

HIPAA Privacy and Security HIPAA Privacy and Security Cindy Cummings, RHIT February, 2015 1 HIPAA Privacy and Security The regulation is designed to safeguard Protected Health Information referred to PHI AND electronic Protected

More information

organization's patient protected health information (PHI) occurs. as any other federal or state notification law.

organization's patient protected health information (PHI) occurs. as any other federal or state notification law. I. APPLICABILITY Entire organization and its business associate (BAs) and the BA's Subcontractors. II. PURPOSE To provide guidance for breach notification by covered entities and breaches by their business

More information

Revisiting the PHI Breach Under HIPAA and HITECH and Considerations for Ophthalmologists

Revisiting the PHI Breach Under HIPAA and HITECH and Considerations for Ophthalmologists ONCE MORE UNTO THE BREACH, DEAR FRIENDS, ONCE MORE Revisiting the PHI Breach Under HIPAA and HITECH and Considerations for Ophthalmologists Neil H. Ekblom, Esq. 885 Third Avenue, 16th Floor, New York,

More information

HHS announces sweeping changes to the HIPAA Privacy and Security Rules in the final HIPAA Omnibus Rule

HHS announces sweeping changes to the HIPAA Privacy and Security Rules in the final HIPAA Omnibus Rule JANUARY 23, 2013 HHS announces sweeping changes to the HIPAA Privacy and Security Rules in the final HIPAA Omnibus Rule By Linn Foster Freedman, Kathryn M. Sylvia, Lindsay Maleson, and Brooke A. Lane On

More information

Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style.

Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style. Are You Still HIPAA Compliant? Staying Protected in the Wake of the Omnibus Final Rule Click to edit Master title style March 27, 2013 www.mcguirewoods.com Introductions Holly Carnell McGuireWoods LLP

More information

NACHC Issue Brief Changes to the Health Insurance Portability and Accountability Act Included in ARRA. March 2010

NACHC Issue Brief Changes to the Health Insurance Portability and Accountability Act Included in ARRA. March 2010 NACHC Issue Brief Changes to the Health Insurance Portability and Accountability Act Included in ARRA March 2010 Prepared By: Marisa Guevara and Marcie H. Zakheim Feldesman Tucker Leifer Fidell, LLP 2001

More information

Information Protection Framework: Data Security Compliance and Today s Healthcare Industry

Information Protection Framework: Data Security Compliance and Today s Healthcare Industry Information Protection Framework: Data Security Compliance and Today s Healthcare Industry Executive Summary Today s Healthcare industry is facing complex privacy and data security requirements. The movement

More information

CHART YOUR HIPAA COURSE...

CHART YOUR HIPAA COURSE... CHART YOUR HIPAA COURSE... HHS ISSUES SECURITY BREACH NOTIFICATION RULES PUBLISHED IN FEDERAL REGISTER 8/24/09 EFFECTIVE 9/23/09 The Department of Health and Human Services ( HHS ) has issued interim final

More information

Susan Childs, RN, BSN, CPHRM Dayton Children s Hospital Liz Stock, Esq. Bricker & Eckler LLP Chris Bennington, Esq. INCompliance Consulting

Susan Childs, RN, BSN, CPHRM Dayton Children s Hospital Liz Stock, Esq. Bricker & Eckler LLP Chris Bennington, Esq. INCompliance Consulting Susan Childs, RN, BSN, CPHRM Dayton Children s Hospital Liz Stock, Esq. Bricker & Eckler LLP Chris Bennington, Esq. INCompliance Consulting 7093020v1 2 1 Just performed my first circumcision. I ll be pouring

More information

HIPAA initially went into effect April 14, 2003. HIPAA is a set of rules that is to be followed by doctors, hospitals and other health care providers.

HIPAA initially went into effect April 14, 2003. HIPAA is a set of rules that is to be followed by doctors, hospitals and other health care providers. HIPAA Health Insurance Portability and Accountability Act HIPAA initially went into effect April 14, 2003 HIPAA is a set of rules that is to be followed by doctors, hospitals and other health care providers.

More information

Healthcare Practice. HIPAA/HITECH Act vs. Oregon Consumer Identity Theft Protection Act. February 2010

Healthcare Practice. HIPAA/HITECH Act vs. Oregon Consumer Identity Theft Protection Act. February 2010 Healthcare Practice HIPAA/HITECH Act vs. Oregon Consumer Identity Theft Protection Act February 2010 HIPAA/HITECH Background Healthcare Practice Stephen Rose srose@gsblaw.com 206.464.3939 Ext 1375 Larry

More information

BREVIUM HIPAA BUSINESS ASSOCIATE TERMS AND CONDITIONS

BREVIUM HIPAA BUSINESS ASSOCIATE TERMS AND CONDITIONS BREVIUM HIPAA BUSINESS ASSOCIATE TERMS AND CONDITIONS The following HIPAA Business Associate Terms and Conditions (referred to hereafter as the HIPAA Agreement ) are part of the Brevium Software License

More information

HIPAA BREACH RESPONSE POLICY

HIPAA BREACH RESPONSE POLICY http://dhmh.maryland.gov/sitepages/op02.aspx (OIG) DHMH POLICY 01.03.07 Effective Date: July 22, 2014 I. EXECUTIVE SUMMARY The Department of Health and Mental Hygiene (DHMH) is committed to protecting

More information

Federal Breach Notification Decision Tree and Tools

Federal Breach Notification Decision Tree and Tools Federal Breach Notification and Tools Disclaimer This document is copyright 2013 by the Long Term Care Consortium (LTCC). These materials may be reproduced and used only by long-term health care providers

More information

HIPAA/HITECH: A Guide for IT Service Providers

HIPAA/HITECH: A Guide for IT Service Providers HIPAA/HITECH: A Guide for IT Service Providers Much like Arthur Dent in the opening scene of The Hitchhiker s Guide to the Galaxy (HHGTTG), you re experiencing the impact of new legislation that s infringing

More information

HIPAA Privacy and Security Rules: A Refresher. Marilyn Freeman, RHIA California Area HIPAA Coordinator California Area HIM Consultant

HIPAA Privacy and Security Rules: A Refresher. Marilyn Freeman, RHIA California Area HIPAA Coordinator California Area HIM Consultant HIPAA Privacy and Security Rules: A Refresher Marilyn Freeman, RHIA California Area HIPAA Coordinator California Area HIM Consultant Objectives Provide overview of Health insurance Portability and Accountability

More information

Surviving a HIPAA Breach

Surviving a HIPAA Breach Surviving a HIPAA Breach Robert W. Markette, Jr., CHC Hall, Render, Killian, Heath & Lyman, P.C. (317) 977 1454 rmarkette@hallrender.com DISCLAIMER: The materials and opinions presented by the speaker

More information

HIPAA Breach Notification Interim Final Rule

HIPAA Breach Notification Interim Final Rule HIPAA Breach Notification Interim Final Rule The American Recovery and Reinvestment Act of 2009 ( the Act ) made several changes to the HIPAA privacy rules including adding a requirement for notice to

More information

Data Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm

Data Security and Integrity of e-phi. MLCHC Annual Clinical Conference Worcester, MA Wednesday, November 12, 2014 2:15pm 3:30pm Electronic Health Records: Data Security and Integrity of e-phi Worcester, MA Wednesday, 2:15pm 3:30pm Agenda Introduction Learning Objectives Overview of HIPAA HIPAA: Privacy and Security HIPAA: The Security

More information

HIPAA PRIVACY AND SECURITY RULES BUSINESS ASSOCIATE AGREEMENT BETWEEN. Stewart C. Miller & Co., Inc. (Business Associate) AND

HIPAA PRIVACY AND SECURITY RULES BUSINESS ASSOCIATE AGREEMENT BETWEEN. Stewart C. Miller & Co., Inc. (Business Associate) AND HIPAA PRIVACY AND SECURITY RULES BUSINESS ASSOCIATE AGREEMENT BETWEEN Stewart C. Miller & Co., Inc. (Business Associate) AND City of West Lafayette Flexible Spending Plan (Covered Entity) TABLE OF CONTENTS

More information

Mapping to HIPAA Audit Protocols

Mapping to HIPAA Audit Protocols Mapping to HIPAA Audit Protocols In June 2011, KPMG was awarded the contract to conduct HIPAA audits and develop an audit protocol on behalf of Health and Human Services (HHS) Office for Civil Rights (OCR).

More information

Enforcement of Health Information Privacy & Security Standards Federal Enforcement Through Recent Cases and Tools to Measure Regulatory Compliance

Enforcement of Health Information Privacy & Security Standards Federal Enforcement Through Recent Cases and Tools to Measure Regulatory Compliance Enforcement of Health Information Privacy & Security Standards Federal Enforcement Through Recent Cases and Tools to Measure Regulatory Compliance Iliana Peters, JD, LLM, HHS Office for Civil Rights Kevin

More information

POLICY AUTHORITY Chancellor for Health Sciences and Dean of the School of Medicine

POLICY AUTHORITY Chancellor for Health Sciences and Dean of the School of Medicine Applies To: All HSC, UNMH, UNMCC, UNM-MG Responsible Department: Privacy Office Revised: New 10/2010 Policy Patient Age Group: ( ) N/A ( X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult POLICY STATEMENT

More information

Healthcare Practice. HIPAA/HITECH Act vs. the Washington Data Breach Notification Act. November 2009

Healthcare Practice. HIPAA/HITECH Act vs. the Washington Data Breach Notification Act. November 2009 Healthcare Practice HIPAA/HITECH Act vs. the Washington Data Breach Notification Act November 2009 HIPAA/HITECH Background Healthcare Practice Stephen Rose srose@gsblaw.com 206.464.3939 Ext 1375 Larry

More information

Name of Other Party: Address of Other Party: Effective Date: Reference Number as applicable:

Name of Other Party: Address of Other Party: Effective Date: Reference Number as applicable: PLEASE NOTE: THIS DOCUMENT IS SUBMITTED AS A SAMPLE, FOR INFORMATIONAL PURPOSES ONLY TO ABC ORGANIZATION. HIPAA SOLUTIONS LC IS NOT ENGAGED IN THE PRACTICE OF LAW IN ANY STATE, JURISDICTION, OR VENUE OF

More information

HIPAA, HIPAA Hi-TECH and HIPAA Omnibus Rule

HIPAA, HIPAA Hi-TECH and HIPAA Omnibus Rule HIPAA, HIPAA Hi-TECH and HIPAA Omnibus Rule NYCR-245157 HIPPA, HIPAA HiTECH& the Omnibus Rule A. HIPAA IIHI and PHI Privacy & Security Rule Covered Entities and Business Associates B. HIPAA Hi-TECH Why

More information