tapps-agents 3.5.40__py3-none-any.whl → 3.6.0__py3-none-any.whl

tapps_agents/experts/knowledge/data-privacy-compliance/hipaa.md

@@ -1,385 +1,385 @@
-# HIPAA Compliance
-
-## Overview
-
-The Health Insurance Portability and Accountability Act (HIPAA) is a US federal law that establishes privacy and security standards for protected health information (PHI). HIPAA applies to covered entities (healthcare providers, health plans, healthcare clearinghouses) and their business associates.
-
-## Key Components
-
-### Privacy Rule
-- Establishes standards for protecting PHI
-- Defines permitted uses and disclosures
-- Grants individuals rights over their health information
-- Requires administrative safeguards
-
-### Security Rule
-- Establishes security standards for ePHI
-- Requires administrative, physical, and technical safeguards
-- Applies to electronic protected health information
-- Requires risk analysis and risk management
-
-### Breach Notification Rule
-- Requires notification of breaches of unsecured PHI
-- Notification to individuals, HHS, and media (if applicable)
-- Timely notification requirements
-
-## Protected Health Information (PHI)
-
-### Definition
-- Individually identifiable health information
-- Created, received, maintained, or transmitted by covered entity
-- Relates to past, present, or future health condition
-- Relates to provision of healthcare
-- Relates to payment for healthcare
-
-### Identifiers
-- Names
-- Geographic subdivisions smaller than state
-- Dates (except year)
-- Telephone numbers
-- Fax numbers
-- Email addresses
-- Social Security numbers
-- Medical record numbers
-- Health plan beneficiary numbers
-- Account numbers
-- Certificate/license numbers
-- Vehicle identifiers
-- Device identifiers
-- Web URLs
-- IP addresses
-- Biometric identifiers
-- Full face photos
-- Any other unique identifier
-
-### De-identification
-- Remove all 18 identifiers
-- Expert determination method
-- Safe harbor method
-- De-identified information is not PHI
-
-## Administrative Safeguards
-
-### Security Management Process
-- Implement policies and procedures
-- Conduct risk analysis
-- Implement risk management
-- Sanction policy
-- Information system activity review
-
-### Assigned Security Responsibility
-- Designate security officer
-- Define security responsibilities
-- Document security officer designation
-
-### Workforce Security
-- Authorization and/or supervision
-- Workforce clearance procedure
-- Termination procedures
-- Access management
-
-### Information Access Management
-- Access authorization
-- Access establishment and modification
-- Access controls
-- Minimum necessary standard
-
-### Security Awareness and Training
-- Security reminders
-- Protection from malicious software
-- Log-in monitoring
-- Password management
-
-### Security Incident Procedures
-- Response and reporting procedures
-- Incident response plan
-- Incident documentation
-- Incident analysis
-
-### Contingency Plan
-- Data backup plan
-- Disaster recovery plan
-- Emergency mode operation plan
-- Testing and revision procedures
-- Applications and data criticality analysis
-
-### Evaluation
-- Periodic technical and non-technical evaluation
-- Assess effectiveness of security measures
-- Document evaluation results
-
-### Business Associate Contracts
-- Written contracts with business associates
-- Specify permitted uses and disclosures
-- Require appropriate safeguards
-- Require breach notification
-
-## Physical Safeguards
-
-### Facility Access Controls
-- Contingency operations
-- Facility security plan
-- Access control and validation procedures
-- Maintenance records
-
-### Workstation Use
-- Implement policies for workstation use
-- Specify functions and physical attributes
-- Restrict access to authorized users
-
-### Workstation Security
-- Implement physical safeguards
-- Restrict access to authorized users
-- Secure workstations
-
-### Device and Media Controls
-- Disposal
-- Media re-use
-- Accountability
-- Data backup and storage
-
-## Technical Safeguards
-
-### Access Control
-- Unique user identification
-- Emergency access procedure
-- Automatic logoff
-- Encryption and decryption
-
-### Audit Controls
-- Hardware, software, and procedural mechanisms
-- Record and examine activity
-- Log access to ePHI
-- Monitor system activity
-
-### Integrity
-- Ensure ePHI is not improperly altered or destroyed
-- Implement mechanisms to authenticate ePHI
-- Electronic signature (if required)
-
-### Transmission Security
-- Integrity controls
-- Encryption (addressable)
-- Secure transmission methods
-- Protect ePHI during transmission
-
-## Minimum Necessary Standard
-
-### Purpose
-- Limit PHI to minimum necessary
-- Reasonable effort to limit access
-- Role-based access controls
-
-### Implementation
-- Define roles and responsibilities
-- Implement access controls
-- Regular access reviews
-- Training on minimum necessary
-
-## Individual Rights
-
-### Right to Access
-- Access to PHI
-- Request in writing
-- Provide within 30 days
-- May charge reasonable fee
-
-### Right to Amendment
-- Request amendment to PHI
-- Accept or deny request
-- Provide written denial with reason
-- Allow statement of disagreement
-
-### Right to Accounting of Disclosures
-- Request accounting of disclosures
-- Provide within 60 days
-- May charge reasonable fee
-- Exceptions apply
-
-### Right to Request Restrictions
-- Request restrictions on uses and disclosures
-- Not required to agree
-- If agreed, must comply
-- Document restrictions
-
-### Right to Request Confidential Communications
-- Request alternative communication methods
-- Reasonable requests must be accommodated
-- Document requests
-
-### Right to Notice of Privacy Practices
-- Provide notice of privacy practices
-- Written in plain language
-- Acknowledge receipt
-- Make available upon request
-
-## Permitted Uses and Disclosures
-
-### Treatment, Payment, and Healthcare Operations
-- Treatment: Provision, coordination, or management of healthcare
-- Payment: Activities to obtain payment
-- Healthcare Operations: Administrative, financial, legal, and quality improvement activities
-
-### Without Authorization
-- Required by law
-- Public health activities
-- Victims of abuse, neglect, or domestic violence
-- Health oversight activities
-- Judicial and administrative proceedings
-- Law enforcement
-- Decedents
-- Cadaveric organ donation
-- Research (with waiver)
-- Workers' compensation
-
-### With Authorization
-- Marketing (with authorization)
-- Sale of PHI (with authorization)
-- Psychotherapy notes (with authorization)
-- Other uses not permitted without authorization
-
-## Business Associate Agreements
-
-### Required Elements
-- Permitted uses and disclosures
-- Appropriate safeguards
-- Breach notification
-- Subcontractor requirements
-- Return or destruction of PHI
-- Authorized uses and disclosures
-- Compliance with Security Rule
-- Report security incidents
-
-### Business Associate Responsibilities
-- Implement appropriate safeguards
-- Use and disclose PHI only as permitted
-- Ensure subcontractors comply
-- Report breaches
-- Return or destroy PHI upon termination
-
-## Breach Notification
-
-### Definition of Breach
-- Unauthorized acquisition, access, use, or disclosure
-- Compromises security or privacy of PHI
-- Poses significant risk of harm
-- Exceptions: unintentional access, inadvertent disclosure, good faith belief
-
-### Individual Notification
-- Without unreasonable delay
-- No later than 60 days after discovery
-- Written notice (or email if preferred)
-- Substitute notice if contact information unavailable
-
-### HHS Notification
-- For breaches affecting 500+ individuals: within 60 days
-- For breaches affecting fewer than 500: within 60 days of end of calendar year
-- Submit through HHS website
-
-### Media Notification
-- For breaches affecting 500+ individuals in state or jurisdiction
-- Without unreasonable delay
-- No later than 60 days after discovery
-
-### Breach Response
-- Investigate breach
-- Mitigate harm
-- Document breach
-- Notify individuals, HHS, and media (if applicable)
-- Review and update security measures
-
-## Risk Analysis and Risk Management
-
-### Risk Analysis
-- Identify ePHI and systems
-- Identify threats and vulnerabilities
-- Assess current security measures
-- Determine likelihood and impact
-- Document findings
-
-### Risk Management
-- Implement security measures
-- Address identified risks
-- Document security measures
-- Regular review and updates
-
-## Encryption
-
-### Encryption at Rest
-- Encrypt ePHI stored on devices
-- Use strong encryption algorithms
-- Manage encryption keys securely
-- Addressable implementation specification
-
-### Encryption in Transit
-- Encrypt ePHI during transmission
-- Use secure transmission methods (TLS/SSL)
-- Protect against interception
-- Addressable implementation specification
-
-## Compliance Checklist
-
-### Administrative Safeguards
-- [ ] Designate security officer
-- [ ] Conduct risk analysis
-- [ ] Implement risk management
-- [ ] Develop security policies and procedures
-- [ ] Implement workforce security measures
-- [ ] Implement information access management
-- [ ] Provide security awareness training
-- [ ] Develop security incident procedures
-- [ ] Develop contingency plan
-- [ ] Execute business associate agreements
-- [ ] Conduct periodic evaluations
-
-### Physical Safeguards
-- [ ] Implement facility access controls
-- [ ] Implement workstation use policies
-- [ ] Implement workstation security
-- [ ] Implement device and media controls
-
-### Technical Safeguards
-- [ ] Implement access controls
-- [ ] Implement audit controls
-- [ ] Implement integrity controls
-- [ ] Implement transmission security
-
-### Privacy Requirements
-- [ ] Develop privacy policies and procedures
-- [ ] Provide notice of privacy practices
-- [ ] Implement minimum necessary standard
-- [ ] Implement individual rights procedures
-- [ ] Train workforce on privacy requirements
-
-### Breach Response
-- [ ] Develop breach response procedures
-- [ ] Implement breach detection mechanisms
-- [ ] Establish notification procedures
-- [ ] Document breach response
-
-## Best Practices
-
-1. **Conduct Regular Risk Analysis**: Identify and address risks
-2. **Implement Strong Access Controls**: Limit access to minimum necessary
-3. **Encrypt ePHI**: Encrypt at rest and in transit
-4. **Train Workforce**: Regular security and privacy training
-5. **Monitor Access**: Log and review access to ePHI
-6. **Manage Business Associates**: Execute and monitor BAAs
-7. **Prepare for Breaches**: Develop and test breach response procedures
-8. **Document Everything**: Maintain comprehensive documentation
-9. **Regular Audits**: Conduct periodic compliance assessments
-10. **Stay Updated**: Monitor changes to HIPAA requirements
-
-## Common Pitfalls
-
-1. **Insufficient Risk Analysis**: Not conducting comprehensive risk analysis
-2. **Weak Access Controls**: Not implementing minimum necessary
-3. **Inadequate Encryption**: Not encrypting ePHI appropriately
-4. **Poor Business Associate Management**: Insufficient BAAs or monitoring
-5. **Inadequate Training**: Workforce not trained on HIPAA requirements
-6. **Poor Breach Response**: Delayed or inadequate breach notification
-7. **Insufficient Documentation**: Missing policies and procedures
-8. **Weak Physical Security**: Inadequate facility and workstation controls
-9. **Inadequate Audit Controls**: Not logging or monitoring access
-10. **Compliance Gaps**: Not addressing all required safeguards
-
+# HIPAA Compliance
+
+## Overview
+
+The Health Insurance Portability and Accountability Act (HIPAA) is a US federal law that establishes privacy and security standards for protected health information (PHI). HIPAA applies to covered entities (healthcare providers, health plans, healthcare clearinghouses) and their business associates.
+
+## Key Components
+
+### Privacy Rule
+- Establishes standards for protecting PHI
+- Defines permitted uses and disclosures
+- Grants individuals rights over their health information
+- Requires administrative safeguards
+
+### Security Rule
+- Establishes security standards for ePHI
+- Requires administrative, physical, and technical safeguards
+- Applies to electronic protected health information
+- Requires risk analysis and risk management
+
+### Breach Notification Rule
+- Requires notification of breaches of unsecured PHI
+- Notification to individuals, HHS, and media (if applicable)
+- Timely notification requirements
+
+## Protected Health Information (PHI)
+
+### Definition
+- Individually identifiable health information
+- Created, received, maintained, or transmitted by covered entity
+- Relates to past, present, or future health condition
+- Relates to provision of healthcare
+- Relates to payment for healthcare
+
+### Identifiers
+- Names
+- Geographic subdivisions smaller than state
+- Dates (except year)
+- Telephone numbers
+- Fax numbers
+- Email addresses
+- Social Security numbers
+- Medical record numbers
+- Health plan beneficiary numbers
+- Account numbers
+- Certificate/license numbers
+- Vehicle identifiers
+- Device identifiers
+- Web URLs
+- IP addresses
+- Biometric identifiers
+- Full face photos
+- Any other unique identifier
+
+### De-identification
+- Remove all 18 identifiers
+- Expert determination method
+- Safe harbor method
+- De-identified information is not PHI
+
+## Administrative Safeguards
+
+### Security Management Process
+- Implement policies and procedures
+- Conduct risk analysis
+- Implement risk management
+- Sanction policy
+- Information system activity review
+
+### Assigned Security Responsibility
+- Designate security officer
+- Define security responsibilities
+- Document security officer designation
+
+### Workforce Security
+- Authorization and/or supervision
+- Workforce clearance procedure
+- Termination procedures
+- Access management
+
+### Information Access Management
+- Access authorization
+- Access establishment and modification
+- Access controls
+- Minimum necessary standard
+
+### Security Awareness and Training
+- Security reminders
+- Protection from malicious software
+- Log-in monitoring
+- Password management
+
+### Security Incident Procedures
+- Response and reporting procedures
+- Incident response plan
+- Incident documentation
+- Incident analysis
+
+### Contingency Plan
+- Data backup plan
+- Disaster recovery plan
+- Emergency mode operation plan
+- Testing and revision procedures
+- Applications and data criticality analysis
+
+### Evaluation
+- Periodic technical and non-technical evaluation
+- Assess effectiveness of security measures
+- Document evaluation results
+
+### Business Associate Contracts
+- Written contracts with business associates
+- Specify permitted uses and disclosures
+- Require appropriate safeguards
+- Require breach notification
+
+## Physical Safeguards
+
+### Facility Access Controls
+- Contingency operations
+- Facility security plan
+- Access control and validation procedures
+- Maintenance records
+
+### Workstation Use
+- Implement policies for workstation use
+- Specify functions and physical attributes
+- Restrict access to authorized users
+
+### Workstation Security
+- Implement physical safeguards
+- Restrict access to authorized users
+- Secure workstations
+
+### Device and Media Controls
+- Disposal
+- Media re-use
+- Accountability
+- Data backup and storage
+
+## Technical Safeguards
+
+### Access Control
+- Unique user identification
+- Emergency access procedure
+- Automatic logoff
+- Encryption and decryption
+
+### Audit Controls
+- Hardware, software, and procedural mechanisms
+- Record and examine activity
+- Log access to ePHI
+- Monitor system activity
+
+### Integrity
+- Ensure ePHI is not improperly altered or destroyed
+- Implement mechanisms to authenticate ePHI
+- Electronic signature (if required)
+
+### Transmission Security
+- Integrity controls
+- Encryption (addressable)
+- Secure transmission methods
+- Protect ePHI during transmission
+
+## Minimum Necessary Standard
+
+### Purpose
+- Limit PHI to minimum necessary
+- Reasonable effort to limit access
+- Role-based access controls
+
+### Implementation
+- Define roles and responsibilities
+- Implement access controls
+- Regular access reviews
+- Training on minimum necessary
+
+## Individual Rights
+
+### Right to Access
+- Access to PHI
+- Request in writing
+- Provide within 30 days
+- May charge reasonable fee
+
+### Right to Amendment
+- Request amendment to PHI
+- Accept or deny request
+- Provide written denial with reason
+- Allow statement of disagreement
+
+### Right to Accounting of Disclosures
+- Request accounting of disclosures
+- Provide within 60 days
+- May charge reasonable fee
+- Exceptions apply
+
+### Right to Request Restrictions
+- Request restrictions on uses and disclosures
+- Not required to agree
+- If agreed, must comply
+- Document restrictions
+
+### Right to Request Confidential Communications
+- Request alternative communication methods
+- Reasonable requests must be accommodated
+- Document requests
+
+### Right to Notice of Privacy Practices
+- Provide notice of privacy practices
+- Written in plain language
+- Acknowledge receipt
+- Make available upon request
+
+## Permitted Uses and Disclosures
+
+### Treatment, Payment, and Healthcare Operations
+- Treatment: Provision, coordination, or management of healthcare
+- Payment: Activities to obtain payment
+- Healthcare Operations: Administrative, financial, legal, and quality improvement activities
+
+### Without Authorization
+- Required by law
+- Public health activities
+- Victims of abuse, neglect, or domestic violence
+- Health oversight activities
+- Judicial and administrative proceedings
+- Law enforcement
+- Decedents
+- Cadaveric organ donation
+- Research (with waiver)
+- Workers' compensation
+
+### With Authorization
+- Marketing (with authorization)
+- Sale of PHI (with authorization)
+- Psychotherapy notes (with authorization)
+- Other uses not permitted without authorization
+
+## Business Associate Agreements
+
+### Required Elements
+- Permitted uses and disclosures
+- Appropriate safeguards
+- Breach notification
+- Subcontractor requirements
+- Return or destruction of PHI
+- Authorized uses and disclosures
+- Compliance with Security Rule
+- Report security incidents
+
+### Business Associate Responsibilities
+- Implement appropriate safeguards
+- Use and disclose PHI only as permitted
+- Ensure subcontractors comply
+- Report breaches
+- Return or destroy PHI upon termination
+
+## Breach Notification
+
+### Definition of Breach
+- Unauthorized acquisition, access, use, or disclosure
+- Compromises security or privacy of PHI
+- Poses significant risk of harm
+- Exceptions: unintentional access, inadvertent disclosure, good faith belief
+
+### Individual Notification
+- Without unreasonable delay
+- No later than 60 days after discovery
+- Written notice (or email if preferred)
+- Substitute notice if contact information unavailable
+
+### HHS Notification
+- For breaches affecting 500+ individuals: within 60 days
+- For breaches affecting fewer than 500: within 60 days of end of calendar year
+- Submit through HHS website
+
+### Media Notification
+- For breaches affecting 500+ individuals in state or jurisdiction
+- Without unreasonable delay
+- No later than 60 days after discovery
+
+### Breach Response
+- Investigate breach
+- Mitigate harm
+- Document breach
+- Notify individuals, HHS, and media (if applicable)
+- Review and update security measures
+
+## Risk Analysis and Risk Management
+
+### Risk Analysis
+- Identify ePHI and systems
+- Identify threats and vulnerabilities
+- Assess current security measures
+- Determine likelihood and impact
+- Document findings
+
+### Risk Management
+- Implement security measures
+- Address identified risks
+- Document security measures
+- Regular review and updates
+
+## Encryption
+
+### Encryption at Rest
+- Encrypt ePHI stored on devices
+- Use strong encryption algorithms
+- Manage encryption keys securely
+- Addressable implementation specification
+
+### Encryption in Transit
+- Encrypt ePHI during transmission
+- Use secure transmission methods (TLS/SSL)
+- Protect against interception
+- Addressable implementation specification
+
+## Compliance Checklist
+
+### Administrative Safeguards
+- [ ] Designate security officer
+- [ ] Conduct risk analysis
+- [ ] Implement risk management
+- [ ] Develop security policies and procedures
+- [ ] Implement workforce security measures
+- [ ] Implement information access management
+- [ ] Provide security awareness training
+- [ ] Develop security incident procedures
+- [ ] Develop contingency plan
+- [ ] Execute business associate agreements
+- [ ] Conduct periodic evaluations
+
+### Physical Safeguards
+- [ ] Implement facility access controls
+- [ ] Implement workstation use policies
+- [ ] Implement workstation security
+- [ ] Implement device and media controls
+
+### Technical Safeguards
+- [ ] Implement access controls
+- [ ] Implement audit controls
+- [ ] Implement integrity controls
+- [ ] Implement transmission security
+
+### Privacy Requirements
+- [ ] Develop privacy policies and procedures
+- [ ] Provide notice of privacy practices
+- [ ] Implement minimum necessary standard
+- [ ] Implement individual rights procedures
+- [ ] Train workforce on privacy requirements
+
+### Breach Response
+- [ ] Develop breach response procedures
+- [ ] Implement breach detection mechanisms
+- [ ] Establish notification procedures
+- [ ] Document breach response
+
+## Best Practices
+
+1. **Conduct Regular Risk Analysis**: Identify and address risks
+2. **Implement Strong Access Controls**: Limit access to minimum necessary
+3. **Encrypt ePHI**: Encrypt at rest and in transit
+4. **Train Workforce**: Regular security and privacy training
+5. **Monitor Access**: Log and review access to ePHI
+6. **Manage Business Associates**: Execute and monitor BAAs
+7. **Prepare for Breaches**: Develop and test breach response procedures
+8. **Document Everything**: Maintain comprehensive documentation
+9. **Regular Audits**: Conduct periodic compliance assessments
+10. **Stay Updated**: Monitor changes to HIPAA requirements
+
+## Common Pitfalls
+
+1. **Insufficient Risk Analysis**: Not conducting comprehensive risk analysis
+2. **Weak Access Controls**: Not implementing minimum necessary
+3. **Inadequate Encryption**: Not encrypting ePHI appropriately
+4. **Poor Business Associate Management**: Insufficient BAAs or monitoring
+5. **Inadequate Training**: Workforce not trained on HIPAA requirements
+6. **Poor Breach Response**: Delayed or inadequate breach notification
+7. **Insufficient Documentation**: Missing policies and procedures
+8. **Weak Physical Security**: Inadequate facility and workstation controls
+9. **Inadequate Audit Controls**: Not logging or monitoring access
+10. **Compliance Gaps**: Not addressing all required safeguards
+