Health Insurance Portability and Accountability Act (HIPAA) Overview

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Health Insurance Portability and Accountability Act (HIPAA) Overview"

Transcription

1 Health Insurance Portability and Accountability Act (HIPAA) Overview Agency, Contract and Temporary Staff Orientation Initiated: 5/04, Reviewed: 7/10, Revised: 10/10 Prepared by SHS Administration & Samaritan Professional Development Page 1 of 8

2 Welcome to this online training! Learning Objectives Upon completion of the module the employee will: Know what HIPAA is and where it came from; Know why we should care about it; Have a basic understanding of the HIPAA standards and their impact on the culture of the organization; Know your role in HIPAA compliance; Discuss appropriate access to protected health information; List three methods available to provide security for patient data; Implement privacy measures for interoffice mail; Place confidential paperwork in the appropriate trash system in his / her department. What is HIPAA? HIPAA is the Health Insurance Portability and Accountability Act. It was originally intended to provide for the continuation of health insurance coverage for individuals when they changed jobs. Background: Where Did HIPAA Come From? Cost Concerns A New England Journal article stated that the United States spends about $400 billion each year on administrative services related to health care. That s around 20% of the total cost of health care each year in the United States. Congress estimated that approximately $87 billion could be saved annually if administrative processes could be improved by: Requiring more health care transactions to be conducted electronically, which would reduce paperwork; and By standardizing health care transactions. Privacy Concerns As more business is conducted electronically, however, it becomes more difficult to protect the privacy of personal data. A national survey revealed that the greatest concern of Americans in this century is that personal health or financial information will be accessible to those who may use or disclose it inappropriately. The increasing availability of personal information on the Internet adds to people s fears. Those fears are increasing as breaches of information security become more publicized, such as hackers and identity thieves accessing and misusing an individual s credit card number. Page 2 of 8

3 Breaches of Patient Privacy Arthur Ashe, the well-known tennis player, contracted AIDS from a blood transfusion and was diagnosed and treated in a Richmond, Virginia hospital. The family asked that this diagnosis be kept confidential, but the information was leaked from the hospital, creating a lot of public concern about the ability of hospitals to treat patient information confidentially. DNA information was used by Burlington Northern Railroad to deny employment to a job applicant. Some other examples of privacy breaches listed below are only a fraction of all cases. A bank accesses records and calls in loans of cancer patients. A medical student sells promising cases to a malpractice lawyer. A hospital Emergency Department employee shares patient information with an attorney for financial gain. Why Should You Care about HIPAA? The first reason is that HIPAA is the law. We don t have the option to simply ignore it. The second reason is that many of the HIPAA standards are incorporated into existing accreditation standards (such as the Joint Commission) as well as annual financial audit procedures. A third reason is that many of the HIPAA regulations make good common sense. Finally, we should care because every employee is impacted by HIPAA and could be penalized for violating HIPAA regulations. HIPAA Privacy and Security Standards Privacy vs. Security - Some Definitions First Page 3 of 8

4 HIPAA Privacy Rule Protected Health Information The Privacy Rule was developed to limit the ways in which information that can be used to identify an individual may be used inside a health care organization or disclosed to outside entities. Protected health information (PHI) is individually identifiable health information that is maintained or transmitted electronically, or in any other form or medium. This means PHI transmitted orally is protected, as well as information that is maintained or transmitted electronically or on paper. Consumer Rights Regarding Their Health Information The hospital is required to give patients a clear written explanation of how they can use and disclose their health information. This is called a Notice of Privacy Practices, and the Privacy Rule identifies specific information that the Notice must contain. Patient have rights to inspect and receive copies of their medical record, to amend their medical record with certain exceptions, to request confidential communications, limitations or restrictions of use or disclosure of PHI, and an accounting of disclosures made by the hospital. There is a duty to mitigate any harm and provide recourse if information is erroneously disclosed. Limitations on the Use or Disclosure of PHI PHI can be used or disclosed without patient authorization only for the purposes of treating the patient, receiving payment for health care services, and health care operations. In most cases, uses or disclosures for any other reason requires written authorization from the patient. o Patients are permitted under the Privacy Rule to revoke an authorization but not retroactively. The Privacy Rule requires that employees only look at the minimum patient health information necessary to do their job. This is called the minimum necessary standard. This standard is required and accepted best practices in the health care industry. o This means that no employee may look up medical information out of curiosity or concern for a family member, friend or anyone else. It is prohibited to simply look at the information (even if you don t tell anyone about what you see) if you are only doing it out of curiosity. You may only look at information for a legitimate business reason. o Inappropriately accessing, disclosing, or sharing PHI will result in disciplinary action up to and including termination. Staff members that do not have a need for PHI to do their jobs should not have access to it. Other Allowable Disclosures The hospital may, however, disclose PHI without the patient s authorization for such things as: o Health care oversight of the hospital, such as quality assurance activities; o Public health requirements; o Emergency or disaster circumstances; Page 4 of 8

5 o Current hospital patient directories; and o Law enforcement purposes. HIPAA Security Standards Electronic Protected Health Information The security standards were written to keep protected health information in electronic form or as it is referred to in the Security Rule, electronic protected health information (EPHI), from being accessed by unauthorized individuals inside and outside the hospital. It requires the hospital to maintain reasonable and appropriate administrative, technical, and physical safeguards to protect that information. The Security Rule is organized into four categories: o Administrative procedures to ensure that threats or violations can be prevented, detected and resolved (security training, hiring practices, system audits); o Physical safeguards to protect EPHI from fire, disaster and unauthorized access (locks, keys, storage protection); o Technical security services to control and monitor access (passwords, audit trails, automatic logoff); o Network security to protect unauthorized access to data transmitted over a network (encryption, detection systems). Your Role and the Security Rule: Make every reasonable effort to protect the privacy of our patient s EPHI. Report any concern about suspected violations of the Security Rule to the SHS Privacy or Security Officer. Access to EPHI through the SHS computer systems should be for patient care or business purposes only. Personal medical information shall not be accessed through the SHS computer systems. Employees who would like to inspect or copy their personal medical information shall complete the proper authorization through the medical records department. SHS takes security issues seriously. Review the specific information provided in the following areas related to the Security Rule: Passwords Passwords should be changed on a regular basis and according to SHS policy. Passwords also should be changed when there is a concern that they might be compromised. o Users are held accountable for password protection. o Users should not share electronic passwords with anyone. o Users should not write down their password or send it via . Each employee is responsible for the security of his/her electronic mail account. Reduce the application to an icon or close the mailbox when not using . Virus Protection Data and software that have been exposed to any computer other than SHS computers must be scanned before installation. This includes downloads from the Internet. Page 5 of 8

6 attachments should not be opened if the sender is unknown. If a virus is suspected or detected: Immediately turn off your computer; Make notes as to what was observed; Contact the Information Services Department Help Desk at Transportation of PHI and EPHI, Including Rules for Laptop Computers Report any loss immediately to your manager or the Information Services Department. All important files must always be backed up to prevent loss of critical data. Back-up discs should be stored in a separate physical location from the computer. Management authorization is required when removing confidential, critical or proprietary data from the hospital. Security of Patient Data Floppy disks or CD s with confidential, critical or proprietary information should be stored in a locked drawer. Turn your computer off when not in use for an extended period of time. Office doors should be locked when the office is not occupied for extended periods of time. Screen protectors are available for computers which may be visible to the public. Employees Are Required to Report: Violations or suspected violations i.e., illegal activity of any kind; suspected use of virus or hacker programs; attempts to damage the SHS organization or an employee of SHS in any way; Inappropriate use of SHS computers i.e., using the computer to communicate inappropriate messages, jokes, or to make harassing or defamatory comments; Breaches of computer security i.e., attempts to circumvent established computer security systems or obtaining or trying to obtain the password of another user. Management Is Responsible for Monitoring Computer Activity in order to: Provide a professional work environment where inappropriate use of computers or SHS computer systems is not tolerated; Reduce the risk of liability and business interruption; Help prevent illegal acts and violation of individual rights. Audits Since audits of user access to the SHS computer systems are a legal requirement under the Security Rule, they will be used to verify appropriate use of the Internet and patient documentation systems. SHS computer systems shall be used principally for patient care or business purposes. Additional Privacy Measures to Review: FAX Machines FAX machines are located in areas that promote confidentiality. A cover sheet with instructions to follow if documents are sent to an unintended recipient should always be used. Page 6 of 8

7 When transmitting medical information: Contact the requestor prior to transmission of documents; and Contact the requestor after transmission to verify receipt of documents If the transmittal record shows that an incorrect number was dialed, immediately fax a cover sheet asking the recipient to call back and request that the documents be mailed back as soon as possible. Interoffice Mail All mail that contains PHI should be placed in a sealed envelope and clearly labeled with the recipient s name. It should then be put in an interdepartmental office envelope for distribution. Confidential Trash See your department specific policy for clarification. Confidential trash is defined as any material that contains: Financial; Administrative, and /or Clinical data And can be associated with the name of any of the following: Patient; Employee; Volunteer; and /or Physician. Confidential trash will be disposed of through established confidential trash systems within each department. A Final Thought Every SHS employee must be familiar with the vision and ethics of the SHS organization as it applies to confidential data, PHI and EPHI. We need to think about who has the legal right to access this information and what is the purpose of the disclosure. It is the responsibility of each employee to protect the privacy and security of confidential data, PHI, and EPHI whether it is on paper, electronic or oral communication. Page 7 of 8

8 Thank you! Page 8 of 8

PHI- Protected Health Information

PHI- Protected Health Information HIPAA Policy 2014 The Health Insurance Portability and Accountability Act is a federal law that protects the privacy and security of patients health information and grants certain rights to patients. Clarkson

More information

HIPAA Security Training Manual

HIPAA Security Training Manual HIPAA Security Training Manual The final HIPAA Security Rule for Montrose Memorial Hospital went into effect in February 2005. The Security Rule includes 3 categories of compliance; Administrative Safeguards,

More information

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 HIPAA

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 HIPAA TRAINING MANUAL HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 HIPAA Table of Contents INTRODUCTION 3 What is HIPAA? Privacy Security Transactions and Code Sets What is covered ADMINISTRATIVE

More information

CREATIVE SOLUTIONS IN HEALTHCARE, INC. Privacy Policy

CREATIVE SOLUTIONS IN HEALTHCARE, INC. Privacy Policy CREATIVE SOLUTIONS IN HEALTHCARE, INC. Privacy Policy Amended as of February 12, 2010 on the authority of the HIPAA Privacy Officer for Creative Solutions in Healthcare, Inc. TABLE OF CONTENTS ARTICLE

More information

HIPAA Awareness Training

HIPAA Awareness Training New York State Office of Mental Health Bureau of Education and Workforce Development HIPAA Awareness Training This training material was prepared for internal use by the New York State Office of Mental

More information

HFS DATA SECURITY TRAINING WITH TECHNOLOGY COMES RESPONSIBILITY

HFS DATA SECURITY TRAINING WITH TECHNOLOGY COMES RESPONSIBILITY HFS DATA SECURITY TRAINING WITH TECHNOLOGY COMES RESPONSIBILITY Illinois Department of Healthcare and Family Services Training Outline: Training Goals What is the HIPAA Security Rule? What is the HFS Identity

More information

HIPAA Compliance. 2013 Annual Mandatory Education

HIPAA Compliance. 2013 Annual Mandatory Education HIPAA Compliance 2013 Annual Mandatory Education What is HIPAA? Health Insurance Portability and Accountability Act Federal Law enacted in 1996 that mandates adoption of Privacy protections for health

More information

Information Technology Security Policies

Information Technology Security Policies Information Technology Security Policies Randolph College 2500 Rivermont Ave. Lynchburg, VA 24503 434-947- 8700 Revised 01/10 Page 1 Introduction Computer information systems and networks are an integral

More information

HIPAA and Mental Health Privacy:

HIPAA and Mental Health Privacy: HIPAA and Mental Health Privacy: What Social Workers Need to Know Presenter: Sherri Morgan, JD, MSW Associate Counsel, NASW Legal Defense Fund and Office of Ethics & Professional Review 2010 National Association

More information

HIPAA Information Security Overview

HIPAA Information Security Overview HIPAA Information Security Overview Security Overview HIPAA Security Regulations establish safeguards for protected health information (PHI) in electronic format. The security rules apply to PHI that is

More information

HIPAA: Bigger and More Annoying

HIPAA: Bigger and More Annoying HIPAA: Bigger and More Annoying Instructor: Laney Kay, JD Contact information: 4640 Hunting Hound Lane Marietta, GA 30062 (770) 312-6257 (770) 998-9204 (fax) laney@laneykay.com www.laneykay.com OFFICIAL

More information

The Internet and e-mail 2 Acceptable use 2 Unacceptable use 2 Downloads 3 Copyrights 3 Monitoring 3. Computer Viruses 3

The Internet and e-mail 2 Acceptable use 2 Unacceptable use 2 Downloads 3 Copyrights 3 Monitoring 3. Computer Viruses 3 Table of Contents 1 Acceptable use 1 Violations 1 Administration 1 Director and Supervisor Responsibilities 1 MIS Director Responsibilities 1 The Internet and e-mail 2 Acceptable use 2 Unacceptable use

More information

8.03 Health Insurance Portability and Accountability Act (HIPAA)

8.03 Health Insurance Portability and Accountability Act (HIPAA) Human Resource/Miscellaneous Page 1 of 5 8.03 Health Insurance Portability and Accountability Act (HIPAA) Policy: It is the policy of Licking/Knox Goodwill Industries, Inc., to maintain the privacy of

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 School Board Policy 523.5 The School District of Black River Falls ( District ) is committed to compliance with the health information

More information

HIPAA Audit Risk Assessment - Risk Factors

HIPAA Audit Risk Assessment - Risk Factors I II Compliance Compliance I Compliance II SECTION ONE COVERED ENTITY RESPONSIBILITIES AREA ONE Notice of Privacy Practices 1 Is your full notice of privacy practices given to every new patient in your

More information

Data Security John Hopkins Core Operations Manager Melanie Williams, Ph.D. Branch Manager Texas Cancer Registry April 17, 2009

Data Security John Hopkins Core Operations Manager Melanie Williams, Ph.D. Branch Manager Texas Cancer Registry April 17, 2009 Data Security John Hopkins Core Operations Manager. Melanie Williams, Ph.D. Branch Manager Texas Cancer Registry April 17, 2009 Background TCR receives approximately 200,000 reports from over 500 reporters

More information

HIPAA Privacy and Security. Rochelle Steimel, HIPAA Privacy Official Judy Smith, Staff Development January 2012

HIPAA Privacy and Security. Rochelle Steimel, HIPAA Privacy Official Judy Smith, Staff Development January 2012 HIPAA Privacy and Security Rochelle Steimel, HIPAA Privacy Official Judy Smith, Staff Development January 2012 Goals and Objectives Course Goal: To introduce the staff of Munson Healthcare to the concepts

More information

HIPAA - Privacy And Security Audit For Provider Practices

HIPAA - Privacy And Security Audit For Provider Practices HIPAA - Privacy And Security Audit For Provider Practices THIS IS A MODEL AUDIT. IT WILL NEED TO BE CHANGED TO MEET THE PARTICULAR NEEDS AND CIRCUMSTANCES OF ANY TRUSTED SOURCES DEVELOPING AN AUDIT. The

More information

Authorized. User Agreement

Authorized. User Agreement Authorized User Agreement CareAccord Health Information Exchange (HIE) Table of Contents Authorized User Agreement... 3 CareAccord Health Information Exchange (HIE) Polices and Procedures... 5 SECTION

More information

Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions

Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions Understanding HIPAA Privacy and Security Helping Your Practice Select a HIPAA- Compliant IT Provider A White Paper by CMIT Solutions Table of Contents Understanding HIPAA Privacy and Security... 1 What

More information

Donna S. Sheperis, PhD, LPC, NCC, CCMHC, ACS Sue Sadik, PhD, LPC, NCC, BC-HSP Carl Sheperis, PhD, LPC, NCC, MAC, ACS

Donna S. Sheperis, PhD, LPC, NCC, CCMHC, ACS Sue Sadik, PhD, LPC, NCC, BC-HSP Carl Sheperis, PhD, LPC, NCC, MAC, ACS Donna S. Sheperis, PhD, LPC, NCC, CCMHC, ACS Sue Sadik, PhD, LPC, NCC, BC-HSP Carl Sheperis, PhD, LPC, NCC, MAC, ACS 1 DISCLAIMER Please review your own documentation with your attorney. This information

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

The Basics of HIPAA Privacy and Security and HITECH

The Basics of HIPAA Privacy and Security and HITECH The Basics of HIPAA Privacy and Security and HITECH Protecting Patient Privacy Disclaimer The content of this webinar is to introduce the principles associated with HIPAA and HITECH regulations and is

More information

Privacy & Security Standards to Protect Patient Information

Privacy & Security Standards to Protect Patient Information Privacy & Security Standards to Protect Patient Information Health Insurance Portability & Accountability Act (HIPAA) 12/16/10 Topics An An Introduction to to HIPAA HIPAA Patient Rights Rights Routine

More information

Protecting Privacy & Security in the Health Care Setting

Protecting Privacy & Security in the Health Care Setting 2013 Compliance Training for Contractors and Vendors Module 3 Protecting Privacy & Security in the Health Care Setting For Internal Training Purposes Only. After completing this training, learners will

More information

HIPAA Education Level One For Volunteers & Observers

HIPAA Education Level One For Volunteers & Observers UK HealthCare HIPAA Education Page 1 September 1, 2009 HIPAA Education Level One For Volunteers & Observers ~ What does HIPAA stand for? H Health I Insurance P Portability A And Accountability A - Act

More information

HIPAA Training for Hospice Staff and Volunteers

HIPAA Training for Hospice Staff and Volunteers HIPAA Training for Hospice Staff and Volunteers Hospice Education Network Objectives Explain the purpose of the HIPAA privacy and security regulations Name three patient privacy rights Discuss what you

More information

HIPAA Privacy & Security Health Insurance Portability and Accountability Act

HIPAA Privacy & Security Health Insurance Portability and Accountability Act HIPAA Privacy & Security Health Insurance Portability and Accountability Act ASSOCIATE EDUCATION St. Elizabeth Medical Center Origin and Purpose of HIPAA In 2003, Congress enacted new rules that would

More information

Jeff M. Bauman, Psy.D. P.A. and Associates FLORIDA-HIPAA PRIVACY NOTICE FORM

Jeff M. Bauman, Psy.D. P.A. and Associates FLORIDA-HIPAA PRIVACY NOTICE FORM Jeff M. Bauman, Psy.D. P.A. and Associates FLORIDA-HIPAA PRIVACY NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL

More information

SELF-LEARNING MODULE (SLM) 2012 HIPAA Education Privacy Basics and Intermediate Modules

SELF-LEARNING MODULE (SLM) 2012 HIPAA Education Privacy Basics and Intermediate Modules SELF-LEARNING MODULE (SLM) 2012 HIPAA Education Privacy Basics and Intermediate Modules Page 2 Index Privacy 101 and Intermediate Privacy Self-Learning Module 2012 HIPAA Education 3 Instructions Index

More information

Clinical Solutions. 2 Hour CEU

Clinical Solutions. 2 Hour CEU 1 2 Hour CEU 2 Course Objectives The purpose of this program is to provide nurses with information about the Health Insurance Portability and Accountability Act (HIPAA), especially as it relates to protected

More information

HIPAA PRIVACY AND SECURITY AWARENESS

HIPAA PRIVACY AND SECURITY AWARENESS HIPAA PRIVACY AND SECURITY AWARENESS Introduction The Health Insurance Portability and Accountability Act (known as HIPAA) was enacted by Congress in 1996. HIPAA serves three main purposes: To protect

More information

Why Lawyers? Why Now?

Why Lawyers? Why Now? TODAY S PRESENTERS Why Lawyers? Why Now? New HIPAA regulations go into effect September 23, 2013 Expands HIPAA safeguarding and breach liabilities for business associates (BAs) Lawyer is considered a business

More information

HIPAA Security Alert

HIPAA Security Alert Shipman & Goodwin LLP HIPAA Security Alert July 2008 EXECUTIVE GUIDANCE HIPAA SECURITY COMPLIANCE How would your organization s senior management respond to CMS or OIG inquiries about health information

More information

HIPAA and Health Information Privacy and Security

HIPAA and Health Information Privacy and Security HIPAA and Health Information Privacy and Security Revised 7/2014 What Is HIPAA? H Health I Insurance P Portability & A Accountability A - Act HIPAA Privacy and Security Rules were passed to protect patient

More information

HIPAA Training for Staff and Volunteers

HIPAA Training for Staff and Volunteers HIPAA Training for Staff and Volunteers Objectives Explain the purpose of the HIPAA privacy, security and breach notification regulations Name three patient privacy rights Discuss what you can do to help

More information

HIPAA Orientation. Health Insurance Portability and Accountability Act

HIPAA Orientation. Health Insurance Portability and Accountability Act HIPAA Orientation Health Insurance Portability and Accountability Act HIPAA Federal legislation enacted in 1996 to improve the efficiency and effectiveness of electronic information transfers used in the

More information

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification

Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Policies and Procedures Audit Checklist for HIPAA Privacy, Security, and Breach Notification Type of Policy and Procedure Comments Completed Privacy Policy to Maintain and Update Notice of Privacy Practices

More information

HIPAA PRIVACY OVERVIEW

HIPAA PRIVACY OVERVIEW HIPAA PRIVACY OVERVIEW OBJECTIVES At the completion of this course, the learner will be able to: Define the Purpose of HIPAA Define Business Associate Identify Patients Rights Understand the Consequences

More information

HIPAA Happenings in Hospital Systems. Donna J Brock, RHIT System HIM Audit & Privacy Coordinator

HIPAA Happenings in Hospital Systems. Donna J Brock, RHIT System HIM Audit & Privacy Coordinator HIPAA Happenings in Hospital Systems Donna J Brock, RHIT System HIM Audit & Privacy Coordinator HIPAA Health Insurance Portability and Accountability Act of 1996 Title 1 Title II Title III Title IV Title

More information

What is HIPAA? The Health Insurance Portability and Accountability Act of 1996

What is HIPAA? The Health Insurance Portability and Accountability Act of 1996 What is HIPAA? The Health Insurance Portability and Accountability Act of 1996 BASIC QUESTIONS AND ANSWERS What Does HIPAA do? Creates national standards to protect individuals' medical records and other

More information

About this Tool Information Security for Residents...

About this Tool Information Security for Residents... About this Tool Information Security for Residents... Purpose: Provide materials to inform and educate Residents in order to reach compliance regarding information security. Audience: New Residents Information

More information

The HIPAA Security Rule Primer A Guide For Mental Health Practitioners

The HIPAA Security Rule Primer A Guide For Mental Health Practitioners The HIPAA Security Rule Primer A Guide For Mental Health Practitioners Distributed by NASW Printer-friendly PDF 2006 APAPO 1 Contents Click on any title below to jump to that page. 1 What is HIPAA? 3 2

More information

BERKELEY COLLEGE DATA SECURITY POLICY

BERKELEY COLLEGE DATA SECURITY POLICY BERKELEY COLLEGE DATA SECURITY POLICY BERKELEY COLLEGE DATA SECURITY POLICY TABLE OF CONTENTS Chapter Title Page 1 Introduction 1 2 Definitions 2 3 General Roles and Responsibilities 4 4 Sensitive Data

More information

Appendix 4-2: Sample HIPAA Security Risk Assessment For a Small Physician Practice

Appendix 4-2: Sample HIPAA Security Risk Assessment For a Small Physician Practice Appendix 4-2: Administrative, Physical, and Technical Safeguards Breach Notification Rule How Use this Assessment The following sample risk assessment provides you with a series of sample questions help

More information

FDOH Information and Privacy Awareness Training Learner Course Guide

FDOH Information and Privacy Awareness Training Learner Course Guide Florida Department of Health FDOH Information and Privacy Awareness Training Learner Course Guide To protect, promote & improve the health of all people in Florida through integrated state, county, & community

More information

PRIVACY AND INFORMATION SECURITY INCIDENT REPORTING

PRIVACY AND INFORMATION SECURITY INCIDENT REPORTING PRIVACY AND INFORMATION SECURITY INCIDENT REPORTING PURPOSE The purpose of this policy is to describe the procedures by which Workforce members of UCLA Health System and David Geffen School of Medicine

More information

HIPAA TRAINING. A training course for Shiawassee County Community Mental Health Authority Employees

HIPAA TRAINING. A training course for Shiawassee County Community Mental Health Authority Employees HIPAA TRAINING A training course for Shiawassee County Community Mental Health Authority Employees WHAT IS HIPAA? HIPAA is an acronym that stands for Health Insurance Portability and Accountability Act.

More information

What Virginia s Free Clinics Need to Know About HIPAA and HITECH

What Virginia s Free Clinics Need to Know About HIPAA and HITECH What Virginia s Free Clinics Need to Know About HIPAA and HITECH This document is one in a series of tools and white papers produced by the Virginia Health Care Foundation to help Virginia s free clinics

More information

HIPAA Compliance for Students

HIPAA Compliance for Students HIPAA Compliance for Students The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 by the United States Congress. It s intent was to help people obtain health insurance benefits

More information

Welcome to ChiroCare s Fourth Annual Fall Business Summit. October 3, 2013

Welcome to ChiroCare s Fourth Annual Fall Business Summit. October 3, 2013 Welcome to ChiroCare s Fourth Annual Fall Business Summit October 3, 2013 HIPAA Compliance Regulatory Overview & Implementation Tips for Providers Agenda Green packet Overview of general HIPAA terms and

More information

ACRONYMS: HIPAA: Health Insurance Portability and Accountability Act PHI: Protected Health Information

ACRONYMS: HIPAA: Health Insurance Portability and Accountability Act PHI: Protected Health Information NAMI EASTSIDE - 13 POLICY: Privacy and Security of Protected Health Information (HIPAA Policies and Procedures) DATE APPROVED: Pending INTENT: (At present, none of the activities that NAMI Eastside provides

More information

NOTICE OF PRIVACY PRACTICES OF THE GROUP HEALTH PLANS SPONSORED BY ACT, INC.

NOTICE OF PRIVACY PRACTICES OF THE GROUP HEALTH PLANS SPONSORED BY ACT, INC. NOTICE OF PRIVACY PRACTICES OF THE GROUP HEALTH PLANS SPONSORED BY ACT, INC. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security Topics

HIPAA Security. 2 Security Standards: Administrative Safeguards. Security Topics HIPAA Security SERIES Security Topics 1. Security 101 for Covered Entities 5. 2. Security Standards - Organizational, Security Policies Standards & Procedures, - Administrative and Documentation Safeguards

More information

CHIS, Inc. Privacy General Guidelines

CHIS, Inc. Privacy General Guidelines CHIS, Inc. and HIPAA CHIS, Inc. provides services to healthcare facilities and uses certain protected health information (PHI) in connection with performing these services. Therefore, CHIS, Inc. is classified

More information

Guadalupe Regional Medical Center

Guadalupe Regional Medical Center Guadalupe Regional Medical Center Health Insurance Portability & Accountability Act (HIPAA) By Debby Hernandez, Compliance/HIPAA Officer HIPAA Privacy & Security Training Module 1 This module will address

More information

HIPAA PRIVACY AND SECURITY AWARENESS. Covering Kids and Families of Indiana April 10, 2014

HIPAA PRIVACY AND SECURITY AWARENESS. Covering Kids and Families of Indiana April 10, 2014 HIPAA PRIVACY AND SECURITY AWARENESS Covering Kids and Families of Indiana April 10, 2014 GOALS AND OBJECTIVES The goal is to provide information to you to promote personal responsibility and behaviors

More information

Notice of Health Information Privacy Practices Radiology Associates of Norwood, Inc.

Notice of Health Information Privacy Practices Radiology Associates of Norwood, Inc. Notice of Health Information 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 THIS NOTICE

More information

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA)

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA) NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA) THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

HIPAA PRIVACY AND SECURITY TRAINING P I E D M O N T COMMUNITY H EA LT H P L A N

HIPAA PRIVACY AND SECURITY TRAINING P I E D M O N T COMMUNITY H EA LT H P L A N HIPAA PRIVACY AND SECURITY TRAINING P I E D M O N T COMMUNITY H EA LT H P L A N 1 COURSE OVERVIEW This course is broken down into 4 modules: Module 1: HIPAA Omnibus Rule - What you need to know to remain

More information

Health Information Privacy Refresher Training. March 2013

Health Information Privacy Refresher Training. March 2013 Health Information Privacy Refresher Training March 2013 1 Disclosure There are no significant or relevant financial relationships to disclose. 2 Topics for Today State health information privacy law Federal

More information

Annual Compliance Training. HITECH/HIPAA Refresher

Annual Compliance Training. HITECH/HIPAA Refresher Annual Compliance Training HITECH/HIPAA Refresher January 2015 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 1 Annual Refresher Training Welcome to the SCL Health System Compliance

More information

SHS Annual Information Security Training

SHS Annual Information Security Training SHS Annual Information Security Training Information Security: What is It? The mission of the SHS Information Security Program is to Protect Valuable SHS Resources Information Security is Everyone s Responsibility

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF 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. Important Notice

More information

INFORMATION TECHNOLOGY Policy 8400 (Regulation 8400) Data Security

INFORMATION TECHNOLOGY Policy 8400 (Regulation 8400) Data Security INFORMATION TECHNOLOGY Policy 8400 (Regulation 8400) Data Security State Fair Community College shall provide a central administrative system for use in data collection and extraction. Any system user

More information

Information Security Policy September 2009 Newman University IT Services. Information Security Policy

Information Security Policy September 2009 Newman University IT Services. Information Security Policy Contents 1. Statement 1.1 Introduction 1.2 Objectives 1.3 Scope and Policy Structure 1.4 Risk Assessment and Management 1.5 Responsibilities for Information Security 2. Compliance 3. HR Security 3.1 Terms

More information

HIPAA Security Rule Compliance

HIPAA Security Rule Compliance HIPAA Security Rule Compliance Caryn Reiker MAXIS360 HIPAA Security Rule Compliance what is it and why you should be concerned about it Table of Contents About HIPAA... 2 Who Must Comply... 2 The HIPAA

More information

Can Your Diocese Afford to Fail a HIPAA Audit?

Can Your Diocese Afford to Fail a HIPAA Audit? Can Your Diocese Afford to Fail a HIPAA Audit? PETULA WORKMAN & PHIL BUSHNELL MAY 2016 2016 ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS Agenda Overview Privacy Security Breach Notification Miscellaneous

More information

INFORMATION TECHNOLOGY SECURITY POLICY COUNTY OF IMPERIAL

INFORMATION TECHNOLOGY SECURITY POLICY COUNTY OF IMPERIAL INFORMATION TECHNOLOGY SECURITY POLICY COUNTY OF IMPERIAL 1 INTRODUCTION The County of Imperial Information & Technical Services (ITS) Security Policy is the foundation of the County's electronic information

More information

The HIPAA Security Rule Primer Compliance Date: April 20, 2005

The HIPAA Security Rule Primer Compliance Date: April 20, 2005 AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE ORGANIZATION Practice Working for You The HIPAA Security Rule Primer Compliance Date: April 20, 2005 Printer-friendly PDF 1 Contents Click on any title below

More information

ACCOUNTABLE HEALTHCARE IPA HIPAA PRIVACY AND SECURITY TRAINING. By: Jerry Jackson Compliance and Privacy Officer

ACCOUNTABLE HEALTHCARE IPA HIPAA PRIVACY AND SECURITY TRAINING. By: Jerry Jackson Compliance and Privacy Officer ACCOUNTABLE HEALTHCARE IPA HIPAA PRIVACY AND SECURITY TRAINING By: Jerry Jackson Compliance and Privacy Officer 1 1 Introduction Welcome to Privacy and Security Training course. This course will help you

More information

Health Insurance Portability and Accountability Act (HIPAA)

Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act (HIPAA) General Education Presented by: Bureau of Personnel Department of Health Department of Human Services Department of Social Services Bureau of

More information

CARING HOSPICE SERVICES NOTICE OF PRIVACY PRACTICES

CARING HOSPICE SERVICES NOTICE OF PRIVACY PRACTICES Original effective date: 2003 Effective date of last Revision: July 17, 2013 CARING HOSPICE SERVICES NOTICE OF PRIVACY PRACTICES Caring Hospice Services of Connecticut Caring Hospice Services of New York

More information

HIPAA Security COMPLIANCE Checklist For Employers

HIPAA Security COMPLIANCE Checklist For Employers Compliance HIPAA Security COMPLIANCE Checklist For Employers All of the following steps must be completed by April 20, 2006 (April 14, 2005 for Large Health Plans) Broadly speaking, there are three major

More information

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210

IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210 IDAHO STATE UNIVERSITY POLICIES AND PROCEDURES (ISUPP) HIPAA Privacy & Security - Sanctions 10210 POLICY INFORMATION Major Functional Area (MFA): MFA X - Office of General Counsel & Compliance Policy Title:

More information

BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050

BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050 BEFORE THE BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON RESOLUTION NO. 05-050 Adopting Multnomah County HIPAA Security Policies and Directing the Appointment of Information System Security

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE

More information

Index .700 FORMS - SAMPLE INCIDENT RESPONSE FORM.995 HISTORY

Index .700 FORMS - SAMPLE INCIDENT RESPONSE FORM.995 HISTORY Information Security Section: General Operations Title: Information Security Number: 56.350 Index POLICY.100 POLICY STATEMENT.110 POLICY RATIONALE.120 AUTHORITY.130 APPROVAL AND EFFECTIVE DATE OF POLICY.140

More information

HIPAA 101: Privacy and Security Basics

HIPAA 101: Privacy and Security Basics HIPAA 101: Privacy and Security Basics Purpose This document provides important information about Kaiser Permanente policies and state and federal laws for protecting the privacy and security of individually

More information

HIPAA and Privacy Policy Training

HIPAA and Privacy Policy Training HIPAA and Privacy Policy Training July 2015 1 This training addresses the requirements for maintaining the privacy of confidential information received from HFS and DHS (the Agencies). During this training

More information

University Healthcare Physicians Compliance and Privacy Policy

University Healthcare Physicians Compliance and Privacy Policy Page 1 of 11 POLICY University Healthcare Physicians (UHP) will enter into business associate agreements in compliance with the provisions of the Health Insurance Portability and Accountability Act of

More information

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I have been provided a copy of Fiorillo Cosmetic and General Dentistry s Notice of Privacy Practices, which has an effective

More information

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

Revelstoke Board of Education Policy Manual

Revelstoke Board of Education Policy Manual Revelstoke Board of Education Policy Manual 3.8 Computer, Internet and BCeSIS Usage and Access This policy shall govern the use of computer equipment, software, the network, e-mail, Internet and BCeSIS

More information

Information Security Policy

Information Security Policy Information Security Policy Touro College/University ( Touro ) is committed to information security. Information security is defined as protection of data, applications, networks, and computer systems

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES The Pain Treatment Center, Inc. d/b/a Stone Road Surgery Center THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE OF PRIVACY PRACTICES

More information

HIPAA PRIVACY DIRECTIONS. HIPAA Privacy/Security Personal Privacy. What is HIPAA? 6/28/2012

HIPAA PRIVACY DIRECTIONS. HIPAA Privacy/Security Personal Privacy. What is HIPAA? 6/28/2012 DIRECTIONS HIPAA Privacy/Security Personal Privacy Catholic Charities On-line Training July 2012 1. Read through entire online training presentation 2. Close the presentation and click on Online Trainings

More information

Advanced Eye Care & Optical 499 E Winchester Blvd., Suite 101 Collierville, TN 38017 Phone: 901-850-2366 Fax: 901-850-2367

Advanced Eye Care & Optical 499 E Winchester Blvd., Suite 101 Collierville, TN 38017 Phone: 901-850-2366 Fax: 901-850-2367 NOTICE OF PRIVACY PRACTICES THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

More information

2.0 Emended due to the change to academy status Review Date. ICT Network Security Policy Berwick Academy

2.0 Emended due to the change to academy status Review Date. ICT Network Security Policy Berwick Academy Version History Author Approved Committee Version Status date Eddie Jefferson 09/15/2009 Full Governing 1.0 Final Version Body Eddie Jefferson 18/08/2012 Full Governing Body 2.0 Emended due to the change

More information

Building a Culture of Health Care Privacy Compliance

Building a Culture of Health Care Privacy Compliance Building a Culture of Health Care Privacy Compliance September 10, 2014 Presented by: Gerry Hinkley, Partner, Pillsbury Greg Radinsky, VP & Chief Corporate Compliance, North Shore - LIJ Wendy Maneval,

More information

C.T. Hellmuth & Associates, Inc.

C.T. Hellmuth & Associates, Inc. Technical Monograph C.T. Hellmuth & Associates, Inc. Technical Monographs usually are limited to only one subject which is treated in considerably more depth than is possible in our Executive Newsletter.

More information

SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI): FOCUS POINTS FOR OFFSITE TRANSCRIPTIONISTS

SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI): FOCUS POINTS FOR OFFSITE TRANSCRIPTIONISTS AMERICAN ASSOCIATION FOR MEDICAL TRANSCRIPTION 100 Sycamore Avenue phone: 800-982-2182 Modesto, CA 95354 fax: 209-527-9633 email: aamt@aamt.org web: www.aamt.org SAFEGUARDING PROTECTED HEALTH INFORMATION

More information

HIPAA Privacy. September 21, 2013

HIPAA Privacy. September 21, 2013 HIPAA Privacy September 21, 2013 HIPAA Privacy Workforce Training The Health Insurance Portability & Accountability Act (HIPAA) requires that the University train all workforce members (faculty, staff,

More information

HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE

HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE HIPAA SECURITY RISK ASSESSMENT SMALL PHYSICIAN PRACTICE How to Use this Assessment The following risk assessment provides you with a series of questions to help you prioritize the development and implementation

More information

Privacy Training for Harvard Medical Students

Privacy Training for Harvard Medical Students HIPAA Training: i Ensuring Privacy for our Patients Privacy Training for Harvard Medical Students Goals By the end of this program you will be able to Explain the basic principles of the Privacy Rule Understand

More information

Executive Vice President of Finance and

Executive Vice President of Finance and Name of Policy: Policy Number: Electronic mail services policy. 3364-65-01 Approving Officer: Administration Executive Vice President of Finance and Responsible Agent: Vice President of Information Technology

More information

Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES

Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES Effective Date of Notice: October 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

More information

SUBJECT: SECURITY OF ELECTRONIC MEDICAL RECORDS COMPLIANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)

SUBJECT: SECURITY OF ELECTRONIC MEDICAL RECORDS COMPLIANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) UNIVERSITY OF PITTSBURGH POLICY SUBJECT: SECURITY OF ELECTRONIC MEDICAL RECORDS COMPLIANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) DATE: March 18, 2005 I. SCOPE This

More information

HIPAA Privacy Policy & Notice of Privacy Practices

HIPAA Privacy Policy & Notice of Privacy Practices HIPAA Privacy Policy & Notice of Privacy Practices 1. PURPOSE 1 The purpose of this policy is to comply with patient personal health information security rights and privacy regulations as outlined in the

More information