The OCR Audit Protocol a first look

Save this PDF as:

Size: px
Start display at page:

Download "The OCR Audit Protocol a first look"

Transcription

1 The OCR Audit Protocol a first look On June 26, 2012, the Office for Civil Rights published its Audit Protocols for HIPAA Security, HIPAA Breach and Privacy at The OCR HIPAA Audit program analyzes processes, controls, and policies of selected covered entities pursuant to the HITECH Act audit mandate. OCR established a comprehensive audit protocol that contains the requirements to be assessed through these performance audits. The entire audit protocol is organized around modules, representing separate elements of privacy, security, and breach notification. The combination of these multiple requirements may vary based on the type of covered entity selected for review. The audit protocol covers Privacy Rule requirements for (1) Notice of privacy practices for PHI, (2) Rights to request privacy protection for PHI, (3) Access of individuals to PHI, (4) Administrative requirements, (5) Uses and disclosures of PHI, (6) Amendment of PHI, and (7) Accounting of disclosures. The protocol covers Security Rule requirements for administrative, physical, and technical safeguards. The protocol covers requirements for the Breach Notification Rule. There are two tables within the protocol, one for HIPAA security with 77 entries and a second table for HIPAA breach and privacy of 88 entries.

2 The tables have the following column headings: Section Established Key Activity Audit Procedures Performance Criteria The security table has a fifth column, Implementation Specification, noted as either addressable, required, or N/A. These headings are not explained or defined. The Section is the Code of Federal Regulations (CFR) section for the specific HIPAA standard for the next 3 or 4 columns. The Established Performance Criteria either is the CFR language or an explanation of what is expected per audit protocol. The Key Activity column outlines what you must be doing such as developing awareness training, content, materials, and methods, or the process steps relating to the overall objective. The Audit Procedures are what the auditor is going to ask you for to prove compliance and implementation. For example, you will be asked for policies, procedures, plans, job descriptions and many other things. Unfortunately the PERFORMANCE CRITERIA cells and the AUDIT PROCEDURE cells data are not all available on the webpage. You must open the cell further to find either the full criteria information or the full audit procedure information. If you choose to print the tables you will not have the complete information of one or the other or both expandable cells. Nor can you expand all the necessary cells before you print. The tables are searchable and you can also do a content sort on webpages.

3 Protocol Review 1. There are enough differences between the two tables that it appears the tables were created by different individuals or different groups. For example in the security table the established performance criteria do not state or include the CFR for each standard section or implementation specification section, yet in the breach and privacy table it is mostly the CFR that is within this column. It would be much more informative if both the standard citation and title and the implementation specification citation and titles were within the established performance criteria cells. 2. The protocols are asking both Code of Federal Regulation (CFR) questions and practical questions. They are asking both these type of questions as you are going to need to prove that you comply with the all the necessary regulation sections for your type of entity and provide evidence of implementation of the regulation sections. For example, for security section (a)(8), Evaluation, you are asked both if you have conducted an evaluation and what type of documentation you have for your evaluation, such as standards and measurements used for evaluation, and findings of an evaluation. 3. Audit procedures ask for formal or informal policies and procedures. I wonder what INFORMAL policies and procedures are!

4 Are both formal and informal policies and procedures written documents? Or are they informal in understanding? Are they casual? Irregular? Unofficial? Unconventional? Perhaps OCR will clarify if enough of the individuals and entities being audited in this round do not understand what informal means. 4. The run of the criteria and audit procedures are not always in the order of the security rule or the privacy rule. For example, , Uses and disclosures for which an authorization or opportunity to agree or object is not required, the research questions and issues come first and not 9 th as they are in the regulation. Then the questions return to asking in order from one forward. 5. Sometimes the compliance questions are asked first and then the practical questions and at other times it is the opposite. There does not appear to be any rhyme or reason for this that I have yet discovered. 6. In , Administrative requirements, (a) Personnel designation of a privacy officer is missing from the privacy table, yet in the security table the security official questions are asked. I think this is just an oversight! 7. In the security (b), Workstation use, section two key activities (Identify workstation types and functions or uses, and Identify expected performance of each type of workstation) have identical audit procedures, which is not useful as one

5 activity is a listing of types, functions and uses, and the other is a performance question. 8. Several of the key activities or audit procedures ask for work that may appear to be neither CFR compliance, nor evidence of implementation. You may want to consult your attorney or compliance office to help you interpret these areas. Conclusion The OCR protocols give the industry much more information than the initial documents request that were released after the first 20 entities were audited. Each type of covered entity and business associate can now plan their own audit using the information on the OCR website. Any entity that has used the NIST HIPAA Security toolkit, using either version, will have many of the answers they need for the OCR HIPAA security protocol to demonstrate compliance with the section and have documented evidence of implementation as well. MalvernGroup has created two tables with all expansion entries for criteria and audit procedures columns; they can be found at MalvernGroup plans a comprehensive OCR audit protocol workbook for you to use to do your own bench audit that will be supported by experienced consultants to help you as needed. Look for the workbook at the same URL as above.

OCR HIPAA Security Audit Protocol a second look

OCR HIPAA Security Audit Protocol a second look OCR HIPAA Security Audit Protocol a second look On June 26, 2012, the Office for Civil Rights published its Audit Protocols for HIPAA Security, HIPAA Breach and Privacy at http://ocrnotifications.hhs.gov/hipaa.html.

More information

Privacy and Security Meaningful Use Requirement HIPAA Readiness Review

Privacy and Security Meaningful Use Requirement HIPAA Readiness Review Privacy and Security Meaningful Use Requirement HIPAA Readiness Review REACH - Achieving - Achieving meaningful meaningful use of your use EHR of your EHR Patti Kritzberger, RHIT, CHPS ND e-health Summit

More information

Our Commitment to Information Security

Our Commitment to Information Security Our Commitment to Information Security What is HIPPA? Health Insurance Portability and Accountability Act 1996 The HIPAA Privacy regulations require health care providers and organizations, as well as

More information

OCR HIPAA AUDITS THEY RE BACK!

OCR HIPAA AUDITS THEY RE BACK! OCR HIPAA AUDITS THEY RE BACK! Chris Apgar, CISSP 2016 OVERVIEW OCR Audit Program Overview What to Expect if OCR s Auditors Show Up Potential Penalties and Other OCR Actions How to Prepare for an Audit

More information

HIPAA Privacy, Security and Breach Notification Audits

HIPAA Privacy, Security and Breach Notification Audits HIPAA Privacy, Security and Breach Notification Audits Program Overview & Initial Analysis Verne Rinker JD, MPH 2013 NIST / OCR Security Rule Conference May 21-22, 2013 Program Mandate HITECH Act, Section

More information

What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act

What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act What Health Care Entities Need to Know about HIPAA and the American Recovery and Reinvestment Act by Lane W. Staines and Cheri D. Green On February 17, 2009, The American Recovery and Reinvestment Act

More information

Neither You Nor Your Business Associates Can Afford to be Lax About Complying with HIPAA Requirements

Neither You Nor Your Business Associates Can Afford to be Lax About Complying with HIPAA Requirements Neither You Nor Your Business Associates Can Afford to be Lax About Complying with HIPAA Requirements Sara Kashing, JD, Staff Attorney July/August 2012 The Therapist If you are considered a Covered Entity

More information

Sample Business Associate Agreement Provisions

Sample Business Associate Agreement Provisions Sample Business Associate Agreement Provisions Words or phrases contained in brackets are intended as either optional language or as instructions to the users of these sample provisions. Definitions Catch-all

More information

Are You Prepared for a HIPAA Audit? 7 Steps to Security Readiness GUIDE BOOK

Are You Prepared for a HIPAA Audit? 7 Steps to Security Readiness GUIDE BOOK Are You Prepared for a HIPAA Audit? 7 Steps to Security Readiness GUIDE BOOK Are You Ready? For nearly four years, official HIPAA compliance audits have been on hold. The Department of Human Services (HHS)

More information

Tools to Prepare and Protect Your Practice for HIPAA and Meaningful Use Audits

Tools to Prepare and Protect Your Practice for HIPAA and Meaningful Use Audits Tools to Prepare and Protect Your Practice for HIPAA and Meaningful Use Audits Presented by: Don Waechter, Managing Partner Health Compliance Partners Ann Breitinger, Attorney Blalock Walters Legal Disclaimer

More information

HIPAA Business Associate Contract. Definitions

HIPAA Business Associate Contract. Definitions HIPAA Business Associate Contract Definitions Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the Privacy Rule. Examples of specific definitions:

More information

Agenda. OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2. Linda Sanches, MPH Senior Advisor, Health Information Privacy 4/1/2014

Agenda. OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2. Linda Sanches, MPH Senior Advisor, Health Information Privacy 4/1/2014 OCR Audits of HIPAA Privacy, Security and Breach Notification, Phase 2 Linda Sanches, MPH Senior Advisor, Health Information Privacy HCCA Compliance Institute March 31, 2014 Agenda Background Audit Phase

More information

Business Associate Agreement

Business Associate Agreement Business Associate Agreement This Business Associate Agreement (the Agreement ) is made by and between Business Associate, [Name of Business Associate], and Covered Entity, The Connecticut Center for Health,

More information

STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM

STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES BUSINESS ASSOCIATE ADDENDUM BETWEEN The Division of Health Care Financing and Policy Herein after referred to as the Covered Entity and (Enter Business

More information

Overview of the HIPAA Security Rule

Overview of the HIPAA Security Rule Office of the Secretary Office for Civil Rights () Overview of the HIPAA Security Rule Office for Civil Rights Region IX Alicia Cornish, EOS Sheila Fischer, Supervisory EOS Topics Upon completion of this

More information

2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health

2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health 2015 Minnesota e-health Summit Data Privacy and Security Prevailing Federal Laws for Local Public Health Adam Stone, MBA, CISSP, CIPP/US, ISSMP, HCISPP, CHPS Secure Digital Solutions, LLC 952-544-0234

More information

2012 HIPAA Privacy and Security Audits

2012 HIPAA Privacy and Security Audits Office of the Secretary Office for Civil Rights (OCR) 2012 HIPAA Privacy and Security Audits Linda Sanches OCR Senior Advisor, Health Information Privacy Lead, HIPAA Compliance Audits OCR 1 Agenda Background

More information

HIPAA Overview. Darren Skyles, Partner McGinnis Lochridge. Darren S. Skyles dskyles@mcginnislaw.com

HIPAA Overview. Darren Skyles, Partner McGinnis Lochridge. Darren S. Skyles dskyles@mcginnislaw.com HIPAA Overview Darren Skyles, Partner McGinnis Lochridge HIPAA Health Insurance Portability and Accountability Act of 1996 Electronic transaction and code sets: Adopted standards for electronic transactions

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

Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information

Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information Welcome to the Privacy and Security PowerPoint presentation in the Data Analytics Toolkit. This presentation will provide introductory information about HIPAA, the HITECH-HIPAA Omnibus Privacy Act, how

More information

SECURITY RISK ASSESSMENT SUMMARY

SECURITY RISK ASSESSMENT SUMMARY Providers Business Name: Providers Business Address: City, State, Zip Acronyms NIST FIPS PHI EPHI BA CE EHR HHS IS National Institute of Standards and Technology Federal Information Process Standards Protected

More information

2/9/2012. 2012 HIPAA Privacy and Security Audit Readiness. Table of contents

2/9/2012. 2012 HIPAA Privacy and Security Audit Readiness. Table of contents 2012 HIPAA Privacy and Security Audit Readiness Mark M. Johnson National HIPAA Services Director Table of contents Page Background 2 Regulatory Background and HITECH Impacts 3 Office of Civil Rights (OCR)

More information

Definitions: Policy: Duties and Responsibilities: The Privacy Officer will have the following responsibilities and duties:

Definitions: Policy: Duties and Responsibilities: The Privacy Officer will have the following responsibilities and duties: PRIVACY 1.0 FACILITY PRIVACY OFFICER Scope: Purpose: All subsidiaries of Universal Health Services, Inc., including facilities and UHS of Delaware Inc. (collectively, UHS ), including UHS covered entities

More information

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know

Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Health Care Information Privacy The HIPAA Regulations What Has Changed and What You Need to Know Note: Information provided to NCRA by Melodi Gates, Associate with Patton Boggs, LLC Privacy and data protection

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT THIS HIPAA BUSINESS ASSOCIATE AGREEMENT ( BAA ) is entered into effective the day of, 20 ( Effective Date ), by and between the Regents of the University of Michigan,

More information

Business Associate Agreement (BAA) Guidance

Business Associate Agreement (BAA) Guidance Business Associate Agreement (BAA) Guidance Introduction The purpose of this document is to provide guidance for creating or updating business associate agreements between your Practice ( Covered Entity

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

BUSINESS ASSOCIATE AGREEMENT. Recitals

BUSINESS ASSOCIATE AGREEMENT. Recitals BUSINESS ASSOCIATE AGREEMENT This Agreement is executed this 8 th day of February, 2013, by BETA Healthcare Group. Recitals BETA Healthcare Group consists of BETA Risk Management Authority (BETARMA) and

More information

SECURETexas Health Information Privacy & Security Certification Program FAQs

SECURETexas Health Information Privacy & Security Certification Program FAQs What is the relationship between the Texas Health Services Authority (THSA) and the Health Information Trust Alliance (HITRUST)? The THSA and HITRUST have partnered to help improve the protection of healthcare

More information

HIPAA Privacy Rule Policies

HIPAA Privacy Rule Policies DRAFT - Policies and Procedures PRIVACY OFFICE ASSIGNMENT AND RESPONSIBILITIES APPROVED BY: SUPERCEDES POLICY: Policy #1 ADOPTED: REVISED: REVIEWED: Purpose This policy is designed to assure the establishment

More information

Preparing for and Responding to an OCR HIPAA Audit

Preparing for and Responding to an OCR HIPAA Audit Preparing for and Responding to Carole Klove Carole.Klove@ucsfmedctr.or g Gerry Hinkley gerry.hinkley@pillsburylaw.com SIXTH NATIONAL HIPAA SUMMIT WEST October 10-12, 2012 Overview Background What to expect

More information

Ethics, Privilege, and Practical Issues in Cloud Computing, Privacy, and Data Protection: HIPAA February 13, 2015

Ethics, Privilege, and Practical Issues in Cloud Computing, Privacy, and Data Protection: HIPAA February 13, 2015 Ethics, Privilege, and Practical Issues in Cloud Computing, Privacy, and Data Protection: HIPAA February 13, 2015 Katherine M. Layman Cozen O Connor 1900 Market Street Philadelphia, PA 19103 (215) 665-2746

More information

Health Informa.on Technology Audits: "Meaningful Use" and HIPAA. January 23, 2015 Eli Poliakoff Gary Capps

Health Informa.on Technology Audits: Meaningful Use and HIPAA. January 23, 2015 Eli Poliakoff Gary Capps Health Informa.on Technology Audits: "Meaningful Use" and HIPAA January 23, 2015 Eli Poliakoff Gary Capps 1 HITECH - Related Audits Health Informa.on Technology for Economic and Clinical Health Act ("HITECH")

More information

HIPAA Audits Are Here!

HIPAA Audits Are Here! HIPAA Audits Are Here! How to prepare for and what to expect when OCR comes knocking May 12, 2016 James B. Wieland, Principal, Ober Kaler Emily H. Wein, Principal, Ober Kaler David Holtzman, VP of Compliance,

More information

DRAFT BUSINESS ASSOCIATES AGREEMENT

DRAFT BUSINESS ASSOCIATES AGREEMENT DRAFT BUSINESS ASSOCIATES AGREEMENT THIS AGREEMENT is made this day of, 20, by and among, a Corporation organized under the laws of the State of (hereinafter known as "Covered Entity") and organized under

More information

The HIPAA Audit Program

The HIPAA Audit Program The HIPAA Audit Program Anna C. Watterson Davis Wright Tremaine LLP The U.S. Department of Health and Human Services (HHS) was given authority, and a mandate, to conduct periodic audits of HIPAA 1 compliance

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

BUSINESS ASSOCIATE AGREEMENT HIPAA Omnibus Rule (Final Rule)

BUSINESS ASSOCIATE AGREEMENT HIPAA Omnibus Rule (Final Rule) BUSINESS ASSOCIATE AGREEMENT HIPAA Omnibus Rule (Final Rule) This Business Associate Agreement (the Agreement ), dated September 9, 2013, is entered into by and between ( Covered Entity ) and Schuster

More information

BUSINESS ASSOCIATE AGREEMENT BETWEEN AND COMMISSION ON ACCREDITATION, AMERICAN PSYCHOLOGICAL ASSOCIATION

BUSINESS ASSOCIATE AGREEMENT BETWEEN AND COMMISSION ON ACCREDITATION, AMERICAN PSYCHOLOGICAL ASSOCIATION BUSINESS ASSOCIATE AGREEMENT BETWEEN AND COMMISSION ON ACCREDITATION, AMERICAN PSYCHOLOGICAL ASSOCIATION This Agreement governs the provision of Protected Health Information ("PHI") (as defined in 45 C.F.R.

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 ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT The parties to this ( Agreement ) are, a _New York_ corporation ( Business Associate ) and ( Client ) you, as a user of our on-line health record system (the "System"). BY

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

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

Shipman & Goodwin LLP. HIPAA Alert STIMULUS PACKAGE SIGNIFICANTLY EXPANDS HIPAA REQUIREMENTS

Shipman & Goodwin LLP. HIPAA Alert STIMULUS PACKAGE SIGNIFICANTLY EXPANDS HIPAA REQUIREMENTS Shipman & Goodwin LLP HIPAA Alert March 2009 STIMULUS PACKAGE SIGNIFICANTLY EXPANDS HIPAA REQUIREMENTS The economic stimulus package, officially named the American Recovery and Reinvestment Act of 2009

More information

BUSINESS ASSOCIATE AGREEMENT ( BAA )

BUSINESS ASSOCIATE AGREEMENT ( BAA ) BUSINESS ASSOCIATE AGREEMENT ( BAA ) Pursuant to the terms and conditions specified in Exhibit B of the Agreement (as defined in Section 1.1 below) between EMC (as defined in the Agreement) and Subcontractor

More information

Business Associates, HITECH & the Omnibus HIPAA Final Rule

Business Associates, HITECH & the Omnibus HIPAA Final Rule Business Associates, HITECH & the Omnibus HIPAA Final Rule HIPAA Omnibus Final Rule Changes Business Associates Marissa Gordon-Nguyen, JD, MPH Health Information Privacy Specialist Office for Civil Rights/HHS

More information

OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463. Court Reporters and HIPAA

OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463. Court Reporters and HIPAA Court Reporters and HIPAA OCRA Spring Convention ~ 2014 Phyllis Craver Lykken, RPR, CLR, CCR 2463 1 What Exactly is HIPAA? HIPAA is an acronym for the Health Insurance Portability and Accountability Act

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

DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES POLICIES AND PROCEDURES Subject: ADMINISTRATION OF HIPAA Effective Date: 12/15/03 Review Date: 6/8/06 Revision Date: 11/21/06 (All legal citations

More information

BUSINESS ASSOCIATE AGREEMENT. Business Associate. Business Associate shall mean.

BUSINESS ASSOCIATE AGREEMENT. Business Associate. Business Associate shall mean. BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement is made as of the day of, 2010, by and between Methodist Lebonheur Healthcare, on behalf of itself and all of its affiliates ( Covered Entity

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( the Agreement ) is entered into this day of, 20 by and between the Tennessee Chapter of the American Academy of Pediatrics ( Business Associate

More information

Business Associate and Other Agreements

Business Associate and Other Agreements Section 4.3 Implement Business Associate and Other Agreements This tool identifies the types of agreements that may be necessary for a community-based care coordination (CCC) program to have in place in

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT THIS IS A TEMPLATE ONLY. CERTAIN STATES MAY NOT PERMIT THE TYPES OF ACTIVITIES ALLOWED HEREUNDER RELATING TO PROTECTED HEALTH INFORMATION. THUS THIS AGREEMENT MAY NEED TO BE MODIFIED IN ORDER TO COMPLY

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Agreement ( Agreement ) is made and entered into this day of [Month], [Year] by and between [Business Name] ( Covered Entity ), [Type of Entity], whose business address

More information

2016 OCR AUDIT E-BOOK

2016 OCR AUDIT E-BOOK !! 2016 OCR AUDIT E-BOOK About BlueOrange Compliance: We specialize in healthcare information privacy and security solutions. We understand that each organization is busy running its business and that

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) by and between OUR LADY OF LOURDES HEALTH CARE SERVICES, INC., hereinafter referred to as Covered Entity, and hereinafter referred

More information

The Case For HIPAA Risk Assessment. Leader s Guide

The Case For HIPAA Risk Assessment. Leader s Guide 4547 The Case For HIPAA Risk Assessment Leader s Guide IMPORTANT INFORMATION FOR EDUCATION COORDINATORS & PROGRAM FACILITATORS PLEASE NOTE: In order for this program to meet Florida course requirements,

More information

Business Associates: HITECH Changes You Need to Know

Business Associates: HITECH Changes You Need to Know Business Associates: HITECH Changes You Need to Know Rebecca L. Williams, RN, JD Partner Co-chair of HIT/HIPAA Practice Davis Wright Tremaine LLP beckywilliams@dwt.com 1 Who Is a Business Associate? A

More information

BUSINESS ASSOCIATE ADDENDUM. WHEREAS, Provider (as defined below) has a contractual relationship with FHCCP requiring this Addendum;

BUSINESS ASSOCIATE ADDENDUM. WHEREAS, Provider (as defined below) has a contractual relationship with FHCCP requiring this Addendum; BUSINESS ASSOCIATE ADDENDUM This BUSINESS ASSOCIATE ADDENDUM (this Addendum ) is made and entered into as of July 1, 2012, ( Effective Date ) and supplements and is made a part of the services agreement

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement ( Agreement ) is entered into as of the day of, 2013 by and between RUTGERS UNIVERSITY, a Hybrid Entity, on behalf and for the

More information

SAMPLE BUSINESS ASSOCIATE AGREEMENT

SAMPLE BUSINESS ASSOCIATE AGREEMENT SAMPLE BUSINESS ASSOCIATE AGREEMENT This is a draft business associate agreement based on the template provided by HHS. It is not intended to be used as is and you should only use the agreement after you

More information

BUSINESS ASSOCIATE PRIVACY AND SECURITY ADDENDUM RECITALS

BUSINESS ASSOCIATE PRIVACY AND SECURITY ADDENDUM RECITALS BUSINESS ASSOCIATE PRIVACY AND SECURITY ADDENDUM This Business Associate Addendum ( Addendum ), effective, 20 ( Effective Date ), is entered into by and between University of Southern California, ( University

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

Lessons Learned from OCR Privacy and Security Audits

Lessons Learned from OCR Privacy and Security Audits Lessons Learned from OCR Privacy and Security Audits Program Overview & Initial Analysis Linda Sanches, MPH Verne Rinker, JD MPH Presentation to IAPP Global Privacy Summit March 7, 2013 Program Mandate

More information

AHLA. B. HIPAA Compliance Audits. Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA

AHLA. B. HIPAA Compliance Audits. Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA AHLA B. HIPAA Compliance Audits Marti Arvin Chief Compliance Officer UCLA Health System and David Geffen School of Medicine Los Angeles, CA Anna C. Watterson Davis Wright Tremaine LLP Washington, DC Fraud

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This Addendum is made part of the agreement between Boston Medical Center ("Covered Entity ) and ( Business Associate"), dated [the Underlying Agreement ]. In connection with

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ), entered into and effective this day of,, is by and between ( Business Associate ) and Black, Gould & Associates, Inc.

More information

BNA s Health Law Reporter

BNA s Health Law Reporter BNA s Health Law Reporter Reproduced with permission from BNA s Health Law Reporter, 20 HLR 1272, 08/18/2011. Copyright 2011 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com HHS

More information

Lessons Learned from HIPAA Audits

Lessons Learned from HIPAA Audits Lessons Learned from HIPAA Audits October 29, 2012 Tony Brooks, CISA, CRISC Partner - IT Assurance and Risk Services HORNE LLP AGENDA HIPAA/HITECH Regulations Breaches and Fines OCR HIPAA/HITECH Compliance

More information

When HHS Calls, Will Your Plan Be HIPAA Compliant?

When HHS Calls, Will Your Plan Be HIPAA Compliant? When HHS Calls, Will Your Plan Be HIPAA Compliant? Petula Workman, J.D., CEBS Division Vice President Compliance Counsel Gallagher Benefit Services, Inc., Sugar Land, Texas The opinions expressed in this

More information

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement ( BAA ) is by and between the National Association of Boards of Pharmacy

More information

FirstCarolinaCare Insurance Company Business Associate Agreement

FirstCarolinaCare Insurance Company Business Associate Agreement FirstCarolinaCare Insurance Company Business Associate Agreement THIS BUSINESS ASSOCIATE AGREEMENT ("Agreement"), is made and entered into as of, 20 (the "Effective Date") between FirstCarolinaCare Insurance

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

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

Coastal Radiology Associates

Coastal Radiology Associates Coastal Radiology Associates 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

More information

Are You Prepared for an OCR HIPAA Audit or Investigation? February 15, 2012 ID Experts Webinar www.idexpertscorp.com

Are You Prepared for an OCR HIPAA Audit or Investigation? February 15, 2012 ID Experts Webinar www.idexpertscorp.com Are You Prepared for an OCR HIPAA Audit or Investigation? February 15, 2012 ID Experts Webinar www.idexpertscorp.com Mahmood Sher-Jan VP of Product Management mahmood.sher-jan@idexpertscorp.com Chris Apgar

More information

HIPAA Enforcement Training for State Attorneys General

HIPAA Enforcement Training for State Attorneys General : State Attorneys General Enforcement of Federal Health Privacy Law HIPAA Enforcement Training for State Attorneys General Module Introduction : Introduction This module of the HIPAA Enforcement Training

More information

BUSINESS ASSOCIATE AGREEMENT

BUSINESS ASSOCIATE AGREEMENT BUSINESS ASSOCIATE AGREEMENT This BUSINESS ASSOCIATE AGREEMENT ( BAA ) is entered into as of ( Effective Date ) by and between ( Covered Entity ) and American Academy of Sleep Medicine ( Business Associate

More information

HIPAA BUSINESS ASSOCIATE ADDENDUM (Privacy & Security) I. Definitions

HIPAA BUSINESS ASSOCIATE ADDENDUM (Privacy & Security) I. Definitions HIPAA BUSINESS ASSOCIATE ADDENDUM (Privacy & Security) I. Definitions A. Business Associate. Business Associate shall have the meaning given to such term under the Privacy and Security Rules, including,

More information

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help

HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help HIPAA Omnibus Compliance How A Data Loss Prevention Solution Can Help The Health Information Portability and Accountability Act (HIPAA) Omnibus Rule which will begin to be enforced September 23, 2013,

More information

SCDA and SCDA Member Benefits Group

SCDA and SCDA Member Benefits Group SCDA and SCDA Member Benefits Group HIPAA Privacy Policy 1. PURPOSE The purpose of this policy is to protect personal health information (PHI) and other personally identifiable information for all individuals

More information

HIPAA BUSINESS ASSOCIATE AGREEMENT

HIPAA BUSINESS ASSOCIATE AGREEMENT HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( BAA ) is effective ( Effective Date ) by and between ( Covered Entity ) and Egnyte, Inc. ( Egnyte or Business Associate ). RECITALS

More information

HIPAA Hot Topics. Audits, the Latest on Enforcement and the Impact of Breaches. September 2012. Nashville Knoxville Memphis Washington, D.C.

HIPAA Hot Topics. Audits, the Latest on Enforcement and the Impact of Breaches. September 2012. Nashville Knoxville Memphis Washington, D.C. HIPAA Hot Topics Audits, the Latest on Enforcement and the Impact of Breaches September 2012 Nashville Knoxville Memphis Washington, D.C. Overview HITECH Act HIPAA Audit Program: update and initial results

More information

UNH Policy on Compliance with the Health Insurance Portability and Accountability Act (HIPAA)

UNH Policy on Compliance with the Health Insurance Portability and Accountability Act (HIPAA) UNH Policy on Compliance with the Health Insurance Portability and Accountability Act (HIPAA) 1 Preamble Approved August 5, 2014 1.1 The Health Insurance Portability and Accountability Act of 1996 (Public

More information

Snake River School District No. 52 HIPAA BUSINESS ASSOCIATE AGREEMENT (See also Policy No. 7436, HIPAA Privacy Rule)

Snake River School District No. 52 HIPAA BUSINESS ASSOCIATE AGREEMENT (See also Policy No. 7436, HIPAA Privacy Rule) 5450F1 (page 1 of 6) Snake River School District No. 52 HIPAA BUSINESS ASSOCIATE AGREEMENT (See also Policy No. 7436, HIPAA Privacy Rule) THIS AGREEMENT is entered into on this day of, 20 by and between

More information

Sunday March 30, 2014, 9am noon HCCA Conference, San Diego

Sunday March 30, 2014, 9am noon HCCA Conference, San Diego Meaningful Use as it Relates to HIPAA Compliance Sunday March 30, 2014, 9am noon HCCA Conference, San Diego CLAconnect.com Objectives and Agenda Understand the statutory and regulatory background and purpose

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. This Notice of

More information

GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY

GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY PLEASE READ THIS WEBSITE PRIVACY POLICY CAREFULLY BEFORE USING THIS WEBSITE, OR SUBMITTING ANY PROTECTED HEALTH INFORMATION OR PERSONALLY IDENTIFIABLE

More information

How to prepare your organization for an OCR HIPAA audit

How to prepare your organization for an OCR HIPAA audit How to prepare your organization for an OCR HIPAA audit Presented By: Mac McMillan, FHIMSS, CISM CEO, CynergisTek, Inc. Technical Assistance: 978-674-8121 or Amanda.Howell@iatric.com Audio Options: Telephone

More information

Data Breach, Electronic Health Records and Healthcare Reform

Data Breach, Electronic Health Records and Healthcare Reform Data Breach, Electronic Health Records and Healthcare Reform (This presentation is for informational purposes only and it is not intended, and should not be relied upon, as legal advice.) Overview of HIPAA

More information

Library Guide: HIPAA

Library Guide: HIPAA Library Guide: HIPAA Page 2 Table of Contents Overview...2 Course Descriptions: Privacy and Security Library: Business Practices to Protect Personal Health Information (HIPAA05)... 3 HIPAA: General Awareness

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

Ensuring Privacy & Security of Patient Information

Ensuring Privacy & Security of Patient Information Ensuring Privacy & Security of Patient Information Danika Brinda, Assistant Professor and REACH P&S Subject Matter Expert Jane McGrath, Program Manager REACH/Stratis Health Session 12, Thursday, June 12,

More information

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant

Developing HIPAA Security Compliance. Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Developing HIPAA Security Compliance Trish Lugtu CPHIMS, CHP, CHSS Health IT Consultant Learning Objectives Identify elements of a HIPAA Security compliance program Learn the HIPAA Security Rule basics

More information

Carl Abramson Gerry Blass Susan A Miller

Carl Abramson Gerry Blass Susan A Miller Introductions 0 Carl Abramson has over 35 years of experience in management consulting, IT management, HIPAA compliance, Critical Infrastructure Cyber Security and business process analysis. Carl is President

More information

Nine Network Considerations in the New HIPAA Landscape

Nine Network Considerations in the New HIPAA Landscape Guide Nine Network Considerations in the New HIPAA Landscape The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Omnibus Final Rule, released January 2013, introduced some significant

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

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES

White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES White Paper THE HIPAA FINAL OMNIBUS RULE: NEW CHANGES IMPACTING BUSINESS ASSOCIATES CONTENTS Introduction 3 Brief Overview of HIPPA Final Omnibus Rule 3 Changes to the Definition of Business Associate

More information

How to Use the NYeC Privacy and Security Toolkit V 1.1

How to Use the NYeC Privacy and Security Toolkit V 1.1 How to Use the NYeC Privacy and Security Toolkit V 1.1 Scope of the Privacy and Security Toolkit The tools included in the Privacy and Security Toolkit serve as guidance for educating stakeholders about

More information

Business Associate Management Methodology

Business Associate Management Methodology Methodology auxilioinc.com 844.874.0684 Table of Contents Methodology Overview 3 Use Case 1: Upstream of s I manage business associates 4 System 5 Use Case 2: Eco System of s I manage business associates

More information