Healthcare Security Policy

HEALTHCARE SECURITY POLICY

Purpose

This Healthcare Security Policy establishes mandatory administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of protected health information (PHI), electronic PHI (ePHI), and other sensitive healthcare data under the control of the organization. All personnel, contractors, vendors, and affiliated parties must comply with the provisions of this policy.

Effective Date and Review

Effective Date:

Next Scheduled Review:

Scope

This policy applies to all workforce members, contractors, vendors, business associates, and volunteers who create, receive, maintain, transmit, or otherwise have access to PHI or systems that store or process healthcare data. It applies to all physical and electronic media, workstations, mobile devices, cloud services, and third-party hosted systems used by the organization.

Definitions

Key terms used in this policy include: PHI — protected health information; ePHI — electronic protected health information; Minimum Necessary — the least amount of information required to accomplish a task; Role-Based Access — access granted based on documented job responsibilities.

Responsibilities

The organization designates specific roles responsible for implementing and enforcing this policy. Select applicable roles for the individual completing this document:

Data Classification and Handling

All information assets are classified and handled according to sensitivity. PHI must be classified as Confidential and handled with the highest protections. The following categories describe common data types handled by this organization:

PHI Types (check all that apply to your department):
Patient demographics Medical records Billing and insurance Imaging and diagnostic data

Access Control

Access to systems and PHI is granted on the basis of least privilege and role-based access. User accounts must be unique, assigned to a documented owner, and revoked promptly upon termination or role change.

Technical Safeguards

Systems processing ePHI must implement encryption in transit and at rest where feasible, multi-factor authentication for privileged access, audit logging, and regular vulnerability management. Mobile devices and removable media containing PHI must be encrypted and approved by IT.

Physical Safeguards

Physical access to areas housing servers, network equipment, and paper records containing PHI must be restricted to authorized personnel. Visitor access must be logged and escorted when in restricted areas.

Incident Response and Breach Notification

All suspected security incidents, unauthorized disclosures, or breaches affecting PHI must be reported immediately to the incident response team. The organization will investigate incidents, contain exposure, and notify affected individuals and authorities as required by applicable law and organizational procedures.

Training and Awareness

All workforce members must complete security and privacy training upon hire and annually thereafter. Training will include PHI handling, phishing awareness, device security, and reporting procedures for suspected incidents.

Audit, Monitoring, and Enforcement

The organization will perform periodic audits of access logs, user privileges, and system configurations. Violations of this policy may result in corrective action, up to and including termination and legal action where appropriate.

Data Retention and Disposal

PHI must be retained and disposed of consistent with legal, regulatory, and contractual obligations. Secure disposal methods such as shredding for paper records and cryptographic erasure or secure wipe for electronic media are required.

Acknowledgment and Applicability to Patients

Patients and authorized representatives may request information on how their PHI is protected. This policy summarizes organizational safeguards. By signing below, the patient or authorized representative acknowledges receipt of this summary and understands how patient data is protected, including the right to request further information upon request.

Patient Information (for Acknowledgment)

Insurance and Medical Information (Optional)

Patient Acknowledgment

By signing below, I acknowledge that I have received a summary of the Healthcare Security Policy, understand how my health information is protected, and understand my rights to request additional information regarding the safeguards and my health information. I understand I may request a copy of the organization's full security and privacy policies.

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