Healthcare Authentication Policy

HEALTHCARE AUTHENTICATION POLICY

Purpose: This Healthcare Authentication Policy establishes mandatory requirements for authentication, credential management, and access control to electronic systems and protected health information. It applies to all individuals and entities granted access to clinical, administrative, billing, or ancillary systems operated by the organization. Effective Date:

1. Scope and Applicability

This policy governs authentication mechanisms for all systems that store, process, or transmit protected health information and related administrative data. Covered persons include employees, contractors, volunteers, vendors, and affiliated clinicians who are issued credentials or granted logical access.

2. Definitions

Authentication: the process used to verify identity prior to granting access. Multi-factor authentication (MFA): the use of two or more independent factors from categories knowledge, possession, and inherence. Privileged account: any account with administrative or elevated system rights.

3. Authentication Requirements

3.1 Passwords: All user passwords must meet minimum complexity and lifecycle controls. Passwords shall be at least 12 characters in length, contain a mix of uppercase and lowercase letters, numbers, and special characters, and must not be based on user-identifiable information. Passwords must be changed at least every 180 days; reuse of the last 24 passwords is prohibited. Shared or group passwords are strictly prohibited except for documented break-glass accounts approved under Section 6.

3.2 Multi-Factor Authentication: MFA is required for remote access, administrative access, access to high-risk clinical systems, and any external-facing interfaces. Acceptable factors include hardware or software tokens, one-time passcodes, smart cards, or biometric factors where supported and subject to privacy safeguards.

3.3 Session Management: Systems must enforce session timeouts after a period of inactivity not to exceed 15 minutes for access to clinical data and 30 minutes for general administrative access. Automatic screen lock is required on devices that access protected systems.

4. Account Provisioning and Deprovisioning

4.1 Provisioning: Access requests must be submitted via approved request channels, include business justification, and be authorized by a designated approver. Provisioning actions must assign least privilege required for the role and be documented in the access control record.

4.2 Deprovisioning: Accounts for separated individuals, contractors, or vendors must be suspended or removed within 24 hours of termination or contract expiration. Temporary access must include an explicit end date and automated removal where possible.

5. Privileged Access and Break-Glass

Privileged accounts require additional controls including MFA, session recording where supported, and quarterly privileged access reviews. Emergency break-glass procedures may be used to restore critical services; all break-glass activity must be logged, justified, and reviewed by security leadership within 48 hours.

6. Remote and Third-Party Access

Remote access by employees and remote access by third parties must use approved secure tunnels and MFA. Third parties must be provisioned under contractual terms defining authentication, logging, and data protection responsibilities. Vendor accounts are subject to the same deprovisioning timelines and access review requirements.

7. Logging, Monitoring and Auditing

Authentication attempts, successes, failures, privilege elevation, and administrative actions must be logged and retained consistent with organizational retention policy. Alerts for anomalous authentication patterns must be configured, documented, and escalated to the security operations function.

8. Incident Response

Suspected credential compromise or authentication system failures must be reported immediately to the security incident response team. Incident procedures include suspension of impacted accounts, forensic logging preservation, notification to affected parties, and remediation steps in accordance with incident handling protocols.

9. Exceptions and Waivers

Exceptions to this policy require written justification and approval by the Chief Information Security Officer or designated delegate. Approved exceptions must include mitigating controls and a defined expiration date.

10. Training, Attestation and Compliance

All covered persons must complete initial authentication and access control training and annual refresher training. Users must attest to understanding and compliance with this policy at least annually. Noncompliance may result in access restrictions, disciplinary action, or contract termination.

11. Policy Review and Change Control

This policy is subject to periodic review and updates. Changes shall be approved by security governance and communicated to affected parties. Documented version history and approval signatures will be maintained in administrative records.

Acknowledgement of Receipt and Understanding

By signing below, I acknowledge that I have received, read, and understand the Healthcare Authentication Policy. I agree to comply with its requirements and understand that violation of this policy may result in disciplinary action up to and including termination of employment or contract.

Patient Staff / Employee Contractor Vendor

Signer Information — Patient (if applicable)

Insurance Information (if patient)

Medical Background (if patient)

Signer Information — Staff / Contractor / Vendor (if applicable)

Certification

I certify under penalty of policy-imposed sanctions that the information provided on this acknowledgement is true and accurate to the best of my knowledge. I understand that my credentials are personal, may not be shared, and that I must report any suspected compromise immediately.

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