HIPAA Service

HIPAA Policies & Procedures for Medical Practices

HIPAA policies should describe how your office actually protects patient information. Atascocita IT helps medical practices in Atascocita, Humble, Kingwood and Northeast Houston develop written Security and Privacy Rule policies based on their risk assessment and everyday workflows, rather than a generic template binder.

Written Security Rule policies and procedures

45 CFR 164.316 requires policies and procedures to implement the Security Rule, maintained in written or electronic form. Required documentation must be retained for six years from its creation or the date it was last in effect, whichever is later. It must be available to the people responsible for implementing the procedures, and reviewed periodically and updated as needed in response to environmental or operational changes affecting the security of electronic protected health information.

Policies and procedures that reflect your office's administrative, physical and technical safeguards
A sanctions policy for workforce members who fail to comply with security policies and procedures (45 CFR 164.308(a)(1)(ii)(C))
Documentation of workforce security awareness and training activities under 45 CFR 164.308(a)(5)
Business associate agreements and related arrangements, where required, under 45 CFR 164.308(b) and 164.504(e)

Privacy policies and the Notice of Privacy Practices

45 CFR 164.530(i) requires covered entities to implement Privacy Rule policies and procedures designed to comply with the rule, taking account of their size and activities. The Notice of Privacy Practices under 45 CFR 164.520 describes permitted uses and disclosures, patient rights and the practice's duties. We review the notice alongside the policies so the documents reflect the practice's actual handling of patient information.

Workforce training and Texas requirements

Policies need to be supported by workforce training and records of that training. Security awareness and training are addressed in 45 CFR 164.308(a)(5); Privacy Rule training and its documentation are addressed in 45 CFR 164.530(b). Texas HB 300 and Texas Health & Safety Code Chapter 181 add training requirements: check current requirements with counsel. Staff acknowledgment forms support your documentation but do not replace training or evidence of completion.

Written for how your office actually works

We use your risk assessment to identify the safeguards and procedures your practice needs, then match the written policies to your EHR, staff responsibilities, vendors and office workflows. A generic template can be a starting point, but a binder that describes controls your office does not use is not a substitute for implemented policies and procedures.

What you receive

The deliverables support implementation and ongoing upkeep of your practice's policies.

A written Security and Privacy Rule policy set matched to your practice
A review of your Notice of Privacy Practices (NPP)
A business associate agreement (BAA) inventory identifying agreements to review or obtain
Staff acknowledgment forms for policy receipt and review
An annual review schedule, with updates also considered when risks, systems or workflows change

Keeping policies current

An annual review schedule is an organizational practice, not a universal HIPAA review deadline. Security Rule documentation must be reviewed periodically and updated as needed, and Privacy Rule policies must be revised when required by changes in law or practice. This page is general information, not legal advice; consult counsel about requirements that apply to your practice.

Frequently asked questions

Do policy templates count?

Templates can help you start, but they must be adapted to your practice and implemented. Written policies should accurately describe your safeguards, staff responsibilities and workflows. Keeping an unchanged template binder does not by itself establish compliance.

How long do we need to keep HIPAA policies?

Under 45 CFR 164.316(b), required Security Rule documentation must be kept for six years from creation or the date it was last in effect, whichever is later. Privacy Rule documentation has a corresponding six-year retention requirement under 45 CFR 164.530(j). This is a documentation rule, not a general medical-record retention rule; other retention requirements should be checked with counsel.

How often should we review our policies?

The Security Rule requires periodic review and updates as needed for changes affecting the security of electronic patient information. Privacy policies also need updates when required by changes in law or practice. We provide an annual review schedule, but changes to your EHR, vendors, risks or workflows may call for earlier updates; HIPAA does not set a universal annual policy-review deadline.

Do small practices need all of these policies?

Small covered practices must meet the applicable HIPAA requirements, including written policies and procedures. The documents can be scaled to the office's size, activities and risks; not every template or vendor agreement applies to every practice. Size alone does not remove the obligation to document and implement applicable safeguards.

How do policies relate to the risk assessment?

The risk assessment identifies threats and vulnerabilities to electronic protected health information. Policies and procedures document how your practice manages those risks and implements safeguards. Reviewing the assessment helps keep the policy set grounded in your actual environment rather than assumptions in a generic template.