1. 🔴 HIPAA Policies and Procedures

• Privacy Policies: Detailed policies on how patient information is collected, used, and disclosed.
• Security Policies: Measures to protect electronic protected health information (ePHI), including administrative, physical, and technical safeguards.
• Breach Notification Policies: Procedures for identifying, responding to, and reporting breaches of PHI.
• Schedule of Audits/Training Log

2. 🔴 Patient Rights - Forms & Notices

• Notice of Privacy Practices (NPP): Informing patients of their rights under HIPAA and how their information will be used.
• Access to PHI: Procedures for patients to access their own health information.
• Amendments to PHI: Processes for patients to request corrections to their health information.
• Accounting of Disclosures: Providing patients with a record of when and why their information has been shared.

3.  🔴 Vendor and Organizational Requirements

• Business Associate Agreements: Contracts with third parties that ensure they comply with HIPAA when handling ePHI.
• Complaint Procedures: Processes for patients to file complaints regarding HIPAA violations.
• Documentation Requirements: Guidelines for maintaining HIPAA related documentation.

4. 🔴 Physical Safeguards

• Facility Access Controls: Measures to control physical access to areas where ePHI is stored.
• Workstation Use and Security: Guidelines for the proper use of workstations that access ePHI.
• Device and Media Controls: Policies for handling and disposing of electronic devices and media that contain ePHI.

5. 🔴 Administrative Safeguards

• Risk Analysis and Management: Regular assessments to identify potential risks to ePHI and steps to mitigate these risks.
• Sanction Policy: Disciplinary actions for employees who violate HIPAA policies.
• Workforce Training: Regular HIPAA training for all staff members to ensure compliance.

6. 🔴  Technical Safeguards

• Access Controls: Policies for ensuring that only authorized personnel have access to ePHI.
• Audit Controls: Procedures for tracking and monitoring access to ePHI.
• Integrity Controls: Measures to ensure that ePHI is not altered or destroyed in an unauthorized manner.
• Transmission Security: Guidelines for protecting ePHI during electronic transmission.

7.  🔴 Incident Response and Reporting

• Incident Response Plan: Steps to take in the event of a security incident or breach.
• Breach Notification: Detailed procedures for notifying affected individuals, the Department of Health and Human Services (HHS), and potentially the media in case of a significant breach.

8. 🔴 Regular Reviews and Updates

• Annual Review: Regularly reviewing and updating the HIPAA manual to ensure compliance with new regulations and changes in the practice.
• Continuous Improvement: Implementing changes based on audit findings, risk assessments, and feedback from staff and patients.

9. 🔴 Resources

•  Templates and Forms: Sample forms and templates for documenting HIPAA compliance activities.
• Resources: Links to additional resources, such as HHS guidelines and compliance checklists.