ABCDEF
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HIPAA Required Operational Actions
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Required Operational ActionDescriptionHIPAA Reference
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1.1Conduct a Security Risk AssessmentConduct a security risk assessment to identify threats and vulnerabilities to the privacy and security of protected health information, evaluate the potential impacts of those threats, and determine the necessary policies, procedures, and security mechanisms to implement in order to mitigate risk45 CFR 164.308(a)(1)(ii)(A)
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1.2Appoint a Chief Security OfficerDesignate staff members (or a staff member) as the organization’s privacy official and security official (which can be the same staff member or two different staff members) who is responsible for the development and implementation of the covered entity’s privacy and security policies and procedure, responding to privacy complaints, and overseeing organizational compliance with HIPAA privacy and security requirements.45 CFR 164.308(a)(2)
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1.3
Appoint a Chief Privacy Officer
45 CFR 164.530(a)(1)(i)
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1.4Develop and Implement Workforce TrainingDevelop and implement a privacy, breach, and security awareness training to ensure staff members comply with HIPAA requirements and the organization’s policies and procedures with respect to protected health information.45 CFR 164.308(5)(i)
45 CFR 164.530(b)(i)
45 CFR 164.530(b)(2)(i)(B)
45 CFR 164.530(b)(2)(ii)
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1.5Develop and Maintain Business Associate Agreements (BAAs)Develop and maintain a business associate agreement with any vendors or subcontractors in order to perform certain payment or health care functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, the participant.45 CFR 164.308(b)
45 CFR 164.314(a)(2)
45 CFR164.502(e)
45 CFR 164.504(e)
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1.6
Develop and Maintain a Notice of Privacy Practices (NPP)
Develop and maintain Notice of Privacy Practices to provide to clients and inform them of potential uses and disclosures of their protected health information and their privacy rights.45 CFR 164.520
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1.7
Develop and Maintain an Authorization Form Allowing for Uses and Disclosures of Clients’ PHI
Develop and maintain an authorization form that individuals must complete to allow for certain uses and disclosures.45 CFR 164.508
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