Customized HIPAA Policies and Procedures

What are HIPAA Privacy and Security Policies and Procedures?

HIPAA policies and procedures provide an essential framework for meeting applicable HIPAA requirements and protecting sensitive health information.
A customized framework designed to establish operational standards, technical safeguards, and administrative protocols to protect Protected Health Information (PHI) within your organization.

HIPAA requires Covered Entities and Business Associates to implement applicable policies and procedures that support compliance with HIPAA requirements. Your HIPAA compliance policy must translate those requirements into practical steps for handling PHI, managing access, responding to incidents, and protecting health information throughout your organization.

HIPAA Policies and Procedures aren’t just a regulatory requirement—they are a foundation for protecting PHI, ensuring operational alignment, and safeguarding your organization’s reputation and bottom line. Don’t rely on generic templates that fail under audit and may not reflect how your organization actually operates. Proactively protect your organization with fully customized HIPAA Policies and Procedures designed around your risks, workforce, and workflows.

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What do Customized HIPAA Policies and Procedures include?

Your customized HIPAA documentation lays the ground rules for daily operations, aligning actual practices with written policy and helping your workforce understand its compliance responsibilities. The following are created using the primary regulations of HIPAA:

Privacy Rule Policies

Address the use and disclosure of PHI, the Minimum Necessary Standard, individual rights, Notice of Privacy Practices (NPP), and roles of the Privacy Officer. These HIPAA procedures help establish consistent expectations for handling PHI throughout your organization.

Security Rule Policies

Define Administrative, Physical, and Technical Safeguards, including access controls, facility security, workforce management, and workstation protection.

Breach Notification & Documentation Protocols

Establish incident response steps, reporting workflows, Business Associate Agreement (BAA) management, and procedures for retaining HIPAA-required documentation for the applicable period.

Utilizing six key steps, we work together to:

1. Gather Data using your Risk Assessment:

Utilize specific data and threat analyses from your Risk Assessment to tailor documentation to your unique workflow.

2. Construct Tailored P&Ps:

We help you develop and implement custom HIPAA policies and procedures that reflect actual operations rather than unworkable boilerplate text.

3. Establish Central Documentation:

Maintain accessibility by storing documents in a centralized, secure documentation library for authorized personnel.

4. Deliver Workforce Training:

Provide customized training presentations that highlight key points of your unique policies to all applicable employees who handle PHI.

5. Assign Key Operational Roles:

Designate Privacy and Information Security Officers and clarify incident reporting and complaint pathways for staff.

6. Review & Maintain Continuously:

Periodically review your documentation with Total HIPAA and update it as needed so written policies continue to reflect your operations, security environment, and applicable regulatory changes.

Why Total HIPAA?

Developing and implementing compliant HIPAA Policies can be overwhelming. Generic templates leave gaps between written requirements and the way your workforce actually uses, accesses, stores, and shares PHI.

Don’t rely on generic templates. Customized HIPAA Policies and Procedures backed by workforce training form an important cornerstone of your organization’s security and compliance posture.

At Total HIPAA, we deliver fully customized HIPAA Privacy and Security Policies and Procedures built around your specific business operations. Instead of simply handing you a generic HIPAA compliance policy, we help connect written requirements to the people and processes responsible for carrying them out.

When Should Policies and Procedures Be Updated?

1. At a Minimum, ANNUALLY

The HIPAA Privacy and Security Rules require all documentation to be reviewed periodically and updated as needed in response to environmental or operational changes affecting electronic PHI. Regular reviews help determine whether your written HIPAA procedures still reflect your technology, workforce, operations, risks, and applicable regulatory requirements.

2. In Response to Significant Operational Changes

Beyond periodic reviews, policies and procedures should be evaluated when environmental or operational changes affect the security or privacy of PHI. This includes:

Implementing new technology: Adopting new software, internal websites, cloud storage, patient portals, or mobile applications
Changing your physical environment: Moving to a new office, adding locations, or updating workstation configurations
Shifting operational procedures: Updating employee workflows, modifying staffing structures, or altering how PHI is shared
After a security incident or breach: Correcting policy deficiencies identified during incident investigation or risk mitigation
When onboarding new workforce members: Integrating applicable policy and security training into your onboarding process helps employees understand their responsibilities for handling PHI from the beginning of their employment.
Changing vendors or services: Reviewing Business Associate Agreements (BAA) and related procedures when vendors begin creating, receiving, maintaining, or transmitting PHI on your organization’s behalf.

3. If You Have an Incident or Breach

A security breach is a daunting scenario, but panic is your biggest enemy. HIPAA regulations require swift, decisive action, and trying to navigate the complex notification and mitigation rules while under pressure can lead to missteps. If a breach occurs, our team stands ready as your dedicated incident response partner. Your policies should establish clear procedures for identifying, reporting, documenting, and responding to suspected incidents, so your team knows what to do when an issue arises.

Frequently Asked Questions About HIPAA Policies and Procedures

What HIPAA policies and procedures does my organization need?

The specific policies you need depend on your role, operations, risks, and use of PHI. Applicable HIPAA policies and procedures may address privacy, access controls, workforce security, incident response, individual rights, disclosures, documentation, Business Associate Agreements, and Administrative, Physical, and Technical Safeguards.

Does HIPAA require written policies and procedures?

Yes. HIPAA requires regulated entities to maintain applicable policies and procedures in written or electronic form. Security Rule policies should be reasonable and appropriate for the organization, while Privacy Rule policies should be designed to support compliance with applicable privacy standards.

How long should HIPAA policies and procedures be retained?

HIPAA requires specified Privacy and Security Rule documentation to be retained for six years from the date it was created or the date it was last in effect, whichever is later. Your organization may have additional retention obligations under other federal or state requirements.

Why choose custom HIPAA policies and procedures instead of templates?

Custom HIPAA policies and procedures reflect how your organization actually operates, including who accesses PHI, how information is stored and transmitted, which vendors interact with PHI, and how staff respond to incidents. Total HIPAA makes written policies practical for your workforce to understand and implement.

Take the first step towards meeting HIPAA requirements and securing your organization.

Let’s get started. Contact us today for a free consultation.

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