HIPAA Security Policies

Definitions and Abbreviations

The following terms appear throughout our security policies and are defined here for clarity.

Identifiable Health Information

Information created or received by a health care provider, health plan, employer, or health care clearinghouse that relates to an individual's health, care, or payment for care and that identifies the individual or could reasonably be used to identify the individual.

Information Systems

An integrated set of components for collecting, storing, and processing data and for providing information, knowledge, and digital products.

Patient Record

A written account of a patient's examination and treatment that includes medical history, complaints, findings, diagnostic results, medications, and procedures.

Protected Health Information (PHI)

Identifiable health information that is transmitted or maintained in any form or medium, excluding the categories listed in 45 CFR 160.103.

Electronic Protected Health Information (ePHI)

Protected health information that is transmitted by electronic media or maintained in electronic media.

Sensitive Information

Information that may identify an individual's health details when combined with other data or that could be used to compromise safeguards protecting health information.

Workforce Members

Employees, volunteers, trainees, and other persons whose conduct, in the performance of work for our organization, is under our direct control whether or not they are paid.

Assigned Security Responsibility

An individual is appointed to oversee and enforce these security policies across the organization.

HIPAA Security Officer Duties

The HIPAA Security Officer maintains and enforces security policies, investigates suspected violations, responds to questions, and communicates policies to workforce members.

Business Associate Oversight

The Security Officer ensures that any business associate managing procedures on our behalf follows the same security standards laid out in our policies.

Regulatory Standard Reference

This responsibility aligns with the Assigned Security Responsibility standard in 45 C.F.R. 164.308(a)(2).

Security Management Process

We implement policies and procedures to prevent, detect, contain, and correct security violations.

Prevent, Detect, Contain, and Correct

Our organizational policies focus on proactive measures that reduce the likelihood of security incidents and provide clear steps for response when they occur.

Risk Analysis Integration

Risk analysis forms a core component of the security management process and guides our selection of reasonable and appropriate security measures.

Risk Management Integration

Findings from the risk analysis drive risk management strategies that lower vulnerabilities to an acceptable level.

Risk Analysis

Risk analysis is an accurate and thorough assessment of potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.

Assessment Scope

The assessment covers all systems and processes that create, receive, maintain, or transmit ePHI.

Frequency of Analysis

We conduct a risk analysis annually or whenever major systems change, business processes shift, or new threats emerge.

Review and Approval

The Security Officer reviews and approves risk analysis procedures, assesses likelihood and impact of identified threats, and determines appropriate security measures.

Risk Management

Security measures are implemented to reduce identified risks and vulnerabilities to a reasonable and appropriate level.

Implementation of Security Measures

Controls are chosen based on risk analysis results to ensure compliance with the HIPAA Security Rule.

Ongoing Monitoring

The Security Officer periodically reviews reports and data from workforce members and business associates to evaluate ongoing risks.

Regulatory Standard Reference

This process aligns with the Risk Management requirement in 45 C.F.R. 164.308(a)(1)(ii)(B).

Sanctions Policy

Appropriate sanctions are applied when workforce members fail to comply with security policies and procedures.

Applying Sanctions

Sanctions are determined in accordance with our Human Resource policies and may range from re‑training to disciplinary action.

Investigation Process

The Security Officer manages investigations into policy violations and documents findings and actions taken.

Regulatory Standard Reference

The sanctions policy supports compliance with the HIPAA Security Rule and related organizational agreements.

Protecting Your Health Information

Our commitment to HIPAA compliance helps protect the confidentiality, integrity, and availability of your health information. We continuously monitor and improve our security measures so you can trust that your data remains safe with our practice.

Last updated: January 2026