Security & Privacy Program Policy

This Policy applies to all workforce members (employees, contractors, interns, and volunteers), business associates, and any other party acting on [Organization]'s behalf, and to all information, systems, applications, devices, facilities, processes, and third-party relationships that create, receive, maintain, or transmit PHI/ePHI or other sensitive information. It governs the entire body of [Organization]'s security and privacy policies and procedures; subordinate policies elaborate specific safeguards and are read as extensions of this one. Workforce members must acknowledge this Policy in writing before being granted access and at least annually thereafter.

Policy

1. Security management process (164.308(a)(1)(i))

[Organization] implements and maintains a documented security management process to prevent, detect, contain, and correct security violations and to reduce risks and vulnerabilities to a reasonable and appropriate level. The process is continuous and consists of four pillars that run throughout the year:

• Prevent: administrative, technical, and physical safeguards (this library), workforce training, least-privilege access, and secure configuration reduce the likelihood of a violation.
• Detect: logging, monitoring, alerting, vulnerability scanning, and activity review surface anomalies and potential violations (see Audit Controls & Activity Review Policy).
• Contain: incident response limits the impact of a violation once detected (see Security Incident Response Policy).
• Correct: risk treatment, remediation tracking, and sanctions address root causes and prevent recurrence.

Risk analysis (§2) and risk management (§3) are the engine of this process; their outputs feed a risk register that drives prioritized correction. The [Security Official] owns the process, and management is committed to providing the resources to operate it. (164.308(a)(1)(i))

2. Risk analysis (164.308(a)(1)(ii)(A))

[Organization] conducts an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all ePHI it creates, receives, maintains, or transmits.

• A comprehensive, organization-wide risk analysis is performed at least annually and upon any significant change to systems, the operating environment, business objectives, or the threat landscape (e.g., adopting a new system that handles ePHI, a material change to facilities, or a significant security incident). Routine maintenance (patching existing systems, redeploying from a previously approved configuration, or onboarding a customer onto an existing platform) does not by itself trigger a new analysis.
• The analysis follows a recognized methodology (NIST SP 800-30 and NIST SP 800-66): characterize systems and where ePHI lives; identify reasonably anticipated threats and vulnerabilities; rate each risk by likelihood × impact; and document the results.
• Every identified risk is recorded in the risk register (§3) with an owner and a planned response. Risk-analysis results are made available to leadership and other key stakeholders to inform business decisions.

The risk-analysis method and the standardized scoring scale are defined in the companion Security & Privacy Program Procedures. (164.308(a)(1)(ii)(A))

3. Risk management (164.308(a)(1)(ii)(B))

[Organization] implements security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level in light of its size, complexity, capabilities, and the likelihood and criticality of potential risks to ePHI. Specifically, the organization will:

• maintain a continuously updated risk register as a living document: each entry carries a risk ID, description, owner, likelihood and impact scores, composite score, treatment decision, remediation status, and target date;
• for each risk requiring treatment, select a disposition: mitigate (select, expand, or develop controls), transfer (e.g., insurance or contractual terms), avoid (discontinue the activity), or accept (only when the cost of other treatment would exceed the potential impact), and record the basis for the decision;
• estimate and record residual risk after planned controls are applied, and re-treat where residual risk remains above tolerance;
• document all risk-management decisions, including deliberate decisions not to implement a given control, and retain that documentation for 6 years;
• track open risks to closure, reviewing remediation progress on a regular cadence defined in the Procedures.

Treatment may combine administrative, physical, and technical safeguards; specific safeguards are implemented through the subordinate policies in this library. (164.308(a)(1)(ii)(B))

4. Assigned security responsibility (164.308(a)(2))

[Organization] designates a single [Security Official] who is responsible for the development, implementation, and ongoing maintenance of the security policies and procedures required by the Security Rule. The [Security Official]:

• owns the security management process, the risk analysis/management program, and this library of policies, and reviews and updates them at least annually and after significant change;
• is accountable to executive leadership (e.g., the CEO/CTO) and is provided the authority and resources to carry out the role;
• ensures security objectives receive appropriate consideration in budgeting and planning;
• facilitates evaluation, audits, training, monitoring, and incident response in coordination with the [Privacy Officer].

The designation is documented and kept current; the contact point is published to the workforce. The [Security Official] and [Privacy Officer] may be the same person in a small or mid-sized organization. (164.308(a)(2))

5. Privacy Officer and contact (164.530(a))

[Organization] designates a [Privacy Officer] responsible for the development and implementation of the privacy policies and procedures, and designates a contact person or office responsible for receiving complaints and providing information about the organization's privacy practices. The [Privacy Officer]:

• maintains the privacy policies and coordinates privacy training with the [Security Official];
• oversees business associate agreements (BAAs) and third-party privacy obligations;
• receives, logs, and addresses privacy complaints and individual-rights requests.

The designation and the contact point ([contact email] / [phone]) are documented and made available to workforce members and to individuals. As above, this role may be held by the same person as the [Security Official]. (164.530(a))

6. Safeguards (administrative, technical, physical) (164.530(c))

[Organization] maintains appropriate administrative, technical, and physical safeguards to protect the privacy of PHI and to reasonably safeguard PHI from any intentional or unintentional use or disclosure that violates the Privacy Rule, and to limit incidental uses and disclosures. These safeguards are the umbrella commitment that the rest of this library implements in detail:

• Administrative: this Security & Privacy Program, workforce security and training, sanctions, access management, incident response, contingency planning, and business associate management.
• Technical: access controls, unique identification and authentication, audit controls, transmission and storage encryption, and integrity controls.
• Physical: facility access controls, workstation use and security, and device and media controls.

Each safeguard is assigned an accountable owner; the safeguard owner matrix is maintained in the companion Security & Privacy Program Procedures. (164.530(c))

7. Periodic evaluation (164.308(a)(8))

[Organization] performs periodic technical and non-technical evaluations of the security program to confirm that policies, procedures, and controls continue to meet the requirements of the Security Rule and remain effective.

• A program-wide evaluation is conducted at least annually and in response to environmental or operational changes materially affecting the security of ePHI.
• The evaluation covers policy and procedure currency, control effectiveness (control self-assessments and, where applicable, independent assessments), and the status of risk-treatment and remediation items.
• Findings are recorded and tracked to resolution, feeding back into the risk register and the security management process (§1).

Technical testing (vulnerability scanning, penetration testing, and detailed control assessments) is governed by the Audit Controls & Activity Review Policy; this Policy requires that their results be incorporated into the annual evaluation. The evaluation checklist is defined in the companion Procedures. (164.308(a)(8))

Roles & Responsibilities

• [Security Official]: owns this Policy, the security management process, and the risk analysis/management program; conducts the periodic evaluation; maintains the policy library.
• [Privacy Officer]: owns privacy policies, the privacy complaint/contact function, and BAA oversight; coordinates with the [Security Official]. (May be the same individual.)
• Executive leadership / management: demonstrate commitment, assign authority and resources, ensure security and privacy objectives align with strategy, and review program outcomes.
• Risk owners: accept assigned risks in the register and drive treatment to completion.
• Safeguard owners: operate and maintain the administrative, technical, and physical safeguards assigned to them.
• Workforce members: comply with all security and privacy policies, cooperate with risk and evaluation activities, and report suspected violations.

Related documents

Security & Privacy Program Procedures · Access Control Policy · Workforce Security, Training & Sanctions Policy · Audit Controls & Activity Review Policy · Security Incident Response Policy · Breach Notification Policy · Business Associate Management Policy · Contingency Planning Policy.

HIPAA controls addressed

Review & version

Reviewed at least annually by the [Security Official] and after any significant change to the ePHI environment. v1.0.