SAMPLE POLICY WORK

employee is assigned access levels that restrict data to only those records relevant to their functions. • Logging and Monitoring: All access attempts to confidential records are logged and monitored automatically. The system records user ID, date, time, and the type of data accessed, generating audit trails for review. • Authorization for Data Sharing: Any sharing of client data with external parties, such as regulatory agencies or third ‑ party service providers, requires prior written authorization from the client (or their legal representative) and must be in accordance with established data sharing protocols. • Verbal Communication: When discussing confidential information verbally (e.g., during shift handovers or interdisciplinary meetings), conversations must occur in private settings. Staff are instructed to avoid mentioning sensitive details in public or unsecured locations. Verification: Internal audits are performed routinely to ensure that access controls are functioning correctly. Any anomalies in access logs are investigated immediately, and adjustments to permissions are made promptly.

4. Transmission of Information

Purpose: When transmitting PHI — whether electronically or verbally — secure protocols must be employed to protect the privacy and integrity of the data during transit.

Procedures:

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Encrypted Electronic Communication: All digital transmissions of sensitive information, including emails, internal memos, and data transfers between systems, must use secure encryption protocols (e.g., SSL/TLS) to prevent interception. • Secure File Transfer Protocols: When transmitting large files or a batch of records, use secure file transfer methods through a Virtual Private Network (VPN) or a secure cloud service that complies with HIPAA guidelines. • Physical Transmission: If documents must be transmitted in physical form, use secure courier services with proven track records for confidentiality and reliability. Sensitive documents are sealed in tamper ‑ proof envelopes and accompanied by a chain ‑ of ‑ custody form. • Verbal Reporting: Sensitive information discussed verbally must be done so in secure, undisrupted locations, away from unauthorized individuals. Staff are trained to use code language or abbreviations if discussion is unavoidable in less secure settings.