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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
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+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   | I |                                                       |   |   |   |
| 2 |   | s |                                                       |   |   |   |
| \ |   | y |                                                       |   |   |   |
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|   |   | s |                                                       |   |   |   |
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+---+---+---+-------------------------------------------------------+---+---+---+
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|   |   | a |                                                       |   |   |   |
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|   |   | t |                                                       |   |   |   |
|   |   | h |                                                       |   |   |   |
|   |   | H |                                                       |   |   |   |
|   |   | I |                                                       |   |   |   |
|   |   | P |                                                       |   |   |   |
|   |   | A |                                                       |   |   |   |
|   |   | A |                                                       |   |   |   |
|   |   | r |                                                       |   |   |   |
|   |   | e |                                                       |   |   |   |
|   |   | q |                                                       |   |   |   |
|   |   | u |                                                       |   |   |   |
|   |   | i |                                                       |   |   |   |
|   |   | r |                                                       |   |   |   |
|   |   | e |                                                       |   |   |   |
|   |   | m |                                                       |   |   |   |
|   |   | e |                                                       |   |   |   |
|   |   | n |                                                       |   |   |   |
|   |   | t |                                                       |   |   |   |
|   |   | s |                                                       |   |   |   |
|   |   | ? |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | **Section II -- Privacy**                             |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization provide notice of privacy      |   |   |   |
| 2 |   |   | practices to your patients?                           |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does the notice include the following information:    |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A description and at least one example of the      |   |   |   |
|   |   |   | types of uses and disclosures that the covered entity |   |   |   |
|   |   |   | is permitted by the privacy regulations to make for   |   |   |   |
|   |   |   | treatment, payment and healthcare operations?         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A description of the other purposes for which the  |   |   |   |
|   |   |   | covered entity is permitted or required by the        |   |   |   |
|   |   |   | privacy regulations to use or disclose PHI without    |   |   |   |
|   |   |   | consent or authorization?                             |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A statement that other uses and disclosures will   |   |   |   |
|   |   |   | be made only with the individual's written            |   |   |   |
|   |   |   | authorization and that the individual may revoke such |   |   |   |
|   |   |   | authorization?                                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -The organization is required by law to protect the   |   |   |   |
|   |   |   | privacy of PHI and provide a notice of its legal      |   |   |   |
|   |   |   | duties and privacy practices with respect to PHI?     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -That the organization is required to abide by the    |   |   |   |
|   |   |   | terms of the notice currently in effect?              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -A statement that the organization reserves the right |   |   |   |
|   |   |   | to change the terms of its notice provisions?         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -How the organization will provide a revised notice?  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -That individuals may complain to the organization    |   |   |   |
|   |   |   | and HHS Secretary if they believe their rights have   |   |   |   |
|   |   |   | been violated?                                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -That if the individual files a complaint, the        |   |   |   |
|   |   |   | organization will not retaliate against them?         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -The name and telephone number of a person to contact |   |   |   |
|   |   |   | for further information?                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization have a procedure for           |   |   |   |
| 4 |   |   | individuals to request a copy of the notice?          |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization have a policy or procedure for |   |   |   |
| 5 |   |   | changing or updating the notice?                      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | If your organization has a web site, has it:          |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Prominently posted the notice on the web site and  |   |   |   |
|   |   |   | made that notice available electronically through the |   |   |   |
|   |   |   | web site?                                             |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If notice is provided by e-mail, has the           |   |   |   |
|   |   |   | individual agreed to such notice?                     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If the e-mail transmission fails, does your        |   |   |   |
|   |   |   | organization provide a paper copy?                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Does your organization allow an individual who has |   |   |   |
|   |   |   | received electronic notice to obtain a paper copy     |   |   |   |
|   |   |   | upon request?                                         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization have policies which ensure     |   |   |   |
| 7 |   |   | that patients are made aware of their individual      |   |   |   |
| \ |   |   | rights as follows:                                    |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- right to access their own PHI                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- right to amend                                     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- right to request restriction of further            |   |   |   |
|   |   |   | disclosures                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- right to request communications in alternative     |   |   |   |
|   |   |   | fashion                                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- right to receive an accounting of disclosures      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- exceptions                                         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization have policies in place         |   |   |   |
| 8 |   |   | concerning the denial of requests for information     |   |   |   |
| \ |   |   | from an individual who is the subject of the PHI in   |   |   |   |
| . |   |   | the following circumstances?                          |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Psychotherapy notes?                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Information complied in anticipation of or for use |   |   |   |
|   |   |   | in a civil, criminal or administrative proceeding?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- PHI that is subject to the Clinical Laboratory     |   |   |   |
|   |   |   | Improvement Amendments of 1988, 42 USC 263(a), or 42  |   |   |   |
|   |   |   | CFR 493.3(a)(2)?                                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 3 |   |   | Does your organization provide for review of the      |   |   |   |
| 9 |   |   | grounds for denial in the following cases:            |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A licensed healthcare professional has determined  |   |   |   |
|   |   |   | in the exercise of professional judgment that access  |   |   |   |
|   |   |   | is reasonably likely to endanger the life or physical |   |   |   |
|   |   |   | safety of the individual or another person?           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- PHI makes reference to another person and a        |   |   |   |
|   |   |   | licensed healthcare professional has determined in    |   |   |   |
|   |   |   | the exercise of professional judgment that access is  |   |   |   |
|   |   |   | reasonably likely to cause substantial harm to such   |   |   |   |
|   |   |   | person?                                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The request is made by the individual's personal   |   |   |   |
|   |   |   | representative and a licensed healthcare professional |   |   |   |
|   |   |   | has determined in the exercise of professional        |   |   |   |
|   |   |   | judgment that access by the personal representative   |   |   |   |
|   |   |   | is reasonably likely to cause substantial harm to the |   |   |   |
|   |   |   | individual or another person?                         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization require requests in writing?   |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization answer requests within 30 days |   |   |   |
| 1 |   |   | unless the information is not on site, and then       |   |   |   |
| \ |   |   | within 60 days?                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | If your organization requires a 30 day extension does |   |   |   |
| 2 |   |   | it provide written notification to the individual     |   |   |   |
| \ |   |   | with the reason for the extension and the date you    |   |   |   |
| . |   |   | will respond to the request?                          |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | If your organization charges a fee, is it reasonable, |   |   |   |
| 3 |   |   | cost-based and did the individual agree to the fee?   |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | If your organization denies the request, does it:     |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Provide the individual a written denial?           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A basis for the denial?                            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A statement of the individual's review rights?     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- A description of how the individual may complain   |   |   |   |
|   |   |   | either to the covered entity or to the Secretary of   |   |   |   |
|   |   |   | HHS?                                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization provide a licensed healthcare  |   |   |   |
| 5 |   |   | professional who was not involved in the denial to    |   |   |   |
| \ |   |   | review the decision?                                  |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization provide the individual with a  |   |   |   |
| 6 |   |   | written notice of the official's decision?            |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization provide an accounting for      |   |   |   |
| 7 |   |   | disclosures of PHI made by a covered entity six years |   |   |   |
| \ |   |   | before the date the individual requests the           |   |   |   |
| . |   |   | accounting except:                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- For treatment, payment and healthcare operations?  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- To individuals of PHI about them?                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- For the facility's directory or to persons         |   |   |   |
|   |   |   | involved in the individual's care?                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- For national security or intelligence purposes?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- To correctional institutions or law enforcement    |   |   |   |
|   |   |   | officials?                                            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- For disclosures that occurred before the           |   |   |   |
|   |   |   | compliance date for the covered entity?               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization have procedures to give        |   |   |   |
| 8 |   |   | individuals an accounting of disclosures when         |   |   |   |
| \ |   |   | required?                                             |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 4 |   |   | Does your organization provide for an accounting of:  |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The date of each disclosure?                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Name and address of the organization or person who |   |   |   |
|   |   |   | received the PHI?                                     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Brief description of the information disclosed?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Brief statement of the purpose for the disclosure, |   |   |   |
|   |   |   | or a copy of the individual's written authorization   |   |   |   |
|   |   |   | or a copy of the written request for disclosure?      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does your organization provide the accounting within  |   |   |   |
| 0 |   |   | 60 days of the request?                               |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | If your organization needs an additional 30 days, do  |   |   |   |
| 1 |   |   | you provide the individual with a written statement   |   |   |   |
| \ |   |   | of the reasons for the extension?                     |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does your organization provide the first accounting   |   |   |   |
| 2 |   |   | within a 12 month period?                             |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does your organization document the information       |   |   |   |
| 3 |   |   | required to be included in the accounting, the        |   |   |   |
| \ |   |   | accounting provided, and the titles of the persons or |   |   |   |
| . |   |   | offices responsible for receiving and processing      |   |   |   |
|   |   |   | requests for an accounting?                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does your organization have procedures to:            |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Enable individuals to request amendment or         |   |   |   |
|   |   |   | correction of PHI?                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- To determine whether the requests should be        |   |   |   |
|   |   |   | granted or denied?                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- To disseminate amendments or corrections to        |   |   |   |
|   |   |   | Business Associates and other to whom erroneous       |   |   |   |
|   |   |   | information has been disclosed?                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | If your organization decides to make an amendment or  |   |   |   |
| 5 |   |   | correction, does your organization provide the        |   |   |   |
| \ |   |   | amendment or correction within 60 days of the         |   |   |   |
| . |   |   | request?                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | If your organization needs an additional 30 days to   |   |   |   |
| 6 |   |   | make an amendment or correction, do you provide the   |   |   |   |
| \ |   |   | individual with a written statement of the reasons    |   |   |   |
| . |   |   | for the extension?                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does your organization inform the individual that the |   |   |   |
| 7 |   |   | amendment or correction has been made and obtain the  |   |   |   |
| \ |   |   | individual's agreement to notify relevant persons     |   |   |   |
| . |   |   | with whom the amendment or correction needs to be     |   |   |   |
|   |   |   | shared?                                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | If your organization denies the request for amendment |   |   |   |
| 8 |   |   | or correction, do they provide a written statement in |   |   |   |
| \ |   |   | plain language of the following:                      |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Basis for the denial?                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Description of how the individual can file a       |   |   |   |
|   |   |   | written statement of disagreement with the denial?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Statement that if the individual does not provide  |   |   |   |
|   |   |   | a statement of denial, that the individual may        |   |   |   |
|   |   |   | request that the covered entity provide the           |   |   |   |
|   |   |   | individual's request for amendment and the denial     |   |   |   |
|   |   |   | with any future disclosures of PHI?                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Statement that the covered entity may provide a    |   |   |   |
|   |   |   | rebuttal to the statement of disagreement in          |   |   |   |
|   |   |   | subsequent disclosures?                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Description of how the individual may complain to  |   |   |   |
|   |   |   | the covered entity or the Secretary of HHS?           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 5 |   |   | Does the description of how the individual may        |   |   |   |
| 9 |   |   | complain include:                                     |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Name and telephone number of the contact person or |   |   |   |
|   |   |   | office of the entity?                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Information relevant to filing a complaint with    |   |   |   |
|   |   |   | the Secretary of HHS?                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization have policies and procedures   |   |   |   |
| 0 |   |   | that specify the process for correction and amendment |   |   |   |
| \ |   |   | of PHI?                                               |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization allow restrictions to uses or  |   |   |   |
| 1 |   |   | disclosures of PHI for treatment, payment or          |   |   |   |
| \ |   |   | healthcare operations or for permitted disclosures to |   |   |   |
| . |   |   | family members involved in the patient's care?        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization terminate a restriction only   |   |   |   |
| 2 |   |   | if the individual agrees or so requests in writing?   |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization have procedures that afford    |   |   |   |
| 3 |   |   | individuals the right to request that your            |   |   |   |
| \ |   |   | organization restrict the manner in which it          |   |   |   |
| . |   |   | communicates with them?                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization have procedures that permit    |   |   |   |
| 4 |   |   | individuals to request that you send communications   |   |   |   |
| \ |   |   | by alternative means or at alternative locations?     |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization accommodate all reasonable     |   |   |   |
| 5 |   |   | requests?                                             |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Has your organization conducted a review to determine |   |   |   |
| 6 |   |   | what data collected is considered protected health    |   |   |   |
| \ |   |   | information (PHI)?                                    |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization have policies regarding the    |   |   |   |
| 7 |   |   | use and disclosure of PHI?                            |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Has your organization reviewed how you currently      |   |   |   |
| 8 |   |   | control who has access to this information?           |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 6 |   |   | Does your organization's current                      |   |   |   |
| 9 |   |   | consent/authorization form allow for the use or       |   |   |   |
| \ |   |   | disclosure of the patient's information?              |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does this consent/authorization comply with the HIPAA |   |   |   |
| 0 |   |   | requirements and any state and federal laws that      |   |   |   |
| \ |   |   | provide stricter confidentiality protection?          |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization disclose only the minimum      |   |   |   |
| 1 |   |   | necessary information when making disclosures in      |   |   |   |
| \ |   |   | circumstances other than to a healthcare provider for |   |   |   |
| . |   |   | treatment, uses and disclosures made to an            |   |   |   |
|   |   |   | individual, uses and disclosures pursuant to an       |   |   |   |
|   |   |   | authorization, or to HHS to enforce compliance?       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization have policies or procedures    |   |   |   |
| 2 |   |   | specifying the minimum necessary information for      |   |   |   |
| \ |   |   | routine uses and disclosures?                         |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Has your organization determined who in your          |   |   |   |
| 3 |   |   | workforce needs access to PHI?                        |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Has your organization specified the category(ies) of  |   |   |   |
| 4 |   |   | PHI to which the individuals need access and any      |   |   |   |
| \ |   |   | appropriate conditions on access?                     |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization review requests for disclosure |   |   |   |
| 5 |   |   | to ensure only the minimum necessary PHI is           |   |   |   |
| \ |   |   | disclosed?                                            |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization provide a copy of the          |   |   |   |
| 6 |   |   | consent/authorization to the individual?              |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization review the                     |   |   |   |
| 7 |   |   | consent/authorization to make sure that the following |   |   |   |
| \ |   |   | elements are in place and that the                    |   |   |   |
| . |   |   | consent/authorization is effective:                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Inform the individual that PHI may be used and     |   |   |   |
|   |   |   | disclosed to carry out treatment, payment and         |   |   |   |
|   |   |   | healthcare operations?                                |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Refer the individual to the statement of privacy   |   |   |   |
|   |   |   | practices for a complete description of such uses and |   |   |   |
|   |   |   | disclosures and state that the individual has the     |   |   |   |
|   |   |   | right to review the notice before signing the         |   |   |   |
|   |   |   | consent?                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If the right to change privacy practices is        |   |   |   |
|   |   |   | reserved, does the organization state that the terms  |   |   |   |
|   |   |   | of the notice may change and describe how the         |   |   |   |
|   |   |   | individual may obtain a revised notice?               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- State that the individual has the right to request |   |   |   |
|   |   |   | that the covered entity restrict how PHI is used or   |   |   |   |
|   |   |   | disclosed to carry out treatment, payment or health   |   |   |   |
|   |   |   | care operations and that although the covered entity  |   |   |   |
|   |   |   | is not required to agree to the restriction, if they  |   |   |   |
|   |   |   | do so, it is binding?                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- State that the individual has the right to revoke  |   |   |   |
|   |   |   | the consent in writing, except to the extent that the |   |   |   |
|   |   |   | covered entity has taken action in reliance on it?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Contain the signature of the individual and the    |   |   |   |
|   |   |   | date signed?                                          |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Contain all other elements required by the Federal |   |   |   |
|   |   |   | Confidentiality Regulations and/or the State Mental   |   |   |   |
|   |   |   | Health Confidentiality Regulations?                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Is the consent/authorization in plain language that   |   |   |   |
| 8 |   |   | is easy to comprehend?                                |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 7 |   |   | Does your organization maintain signed                |   |   |   |
| 9 |   |   | consents/authorizations for six years?                |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Does your organization have policies regarding use    |   |   |   |
| 0 |   |   | and disclosure of PHI for                             |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- medical emergencies?                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- compelled treatments?                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- when there are communication barriers?             |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- when the patient is an inmate?                     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | If your organization uses or discloses PHI in         |   |   |   |
| 1 |   |   | facility directories and/or for involvement by family |   |   |   |
| \ |   |   | members and others in the individual's care and for   |   |   |   |
| . |   |   | notification purposes without consent or              |   |   |   |
|   |   |   | authorization, does your organization inform the      |   |   |   |
|   |   |   | individual in advance that the individual has the     |   |   |   |
|   |   |   | opportunity to agree or restrict the disclosure?      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | If the individual cannot have the opportunity to      |   |   |   |
| 2 |   |   | object because of an emergency situation, does the    |   |   |   |
| \ |   |   | organization only use PHI for a directory to the      |   |   |   |
| . |   |   | extent it is consistent with a prior expressed        |   |   |   |
|   |   |   | preference by the individual?                         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Does the organization use or disclose to a family     |   |   |   |
| 3 |   |   | member, other relative, close personal friend or any  |   |   |   |
| \ |   |   | other person identified by the individual only PHI    |   |   |   |
| . |   |   | directly relevant to such person's involvement with   |   |   |   |
|   |   |   | the individual's care or payment related to that care |   |   |   |
|   |   |   | with:                                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The individual's agreement?                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The individual's non-objection after you have      |   |   |   |
|   |   |   | provided an opportunity to object?                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- An inference, based on the exercise of             |   |   |   |
|   |   |   | professional judgment, that the individual does not   |   |   |   |
|   |   |   | object?                                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Are the use and disclosure of psychotherapy notes     |   |   |   |
| 4 |   |   | covered under your organization's policies?           |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Does your organization obtain authorizations for the  |   |   |   |
| 5 |   |   | use or disclosure of psychotherapy notes EXCEPT:      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- To carry out treatment, payment and healthcare     |   |   |   |
|   |   |   | operations                                            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- When used by the originator of the psychotherapy   |   |   |   |
|   |   |   | notes for treatment?                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- When used or disclosed by the covered entity in    |   |   |   |
|   |   |   | training programs in which students, trainees or      |   |   |   |
|   |   |   | practitioners in mental health learn under            |   |   |   |
|   |   |   | supervision to practice or improve their skills in    |   |   |   |
|   |   |   | group, joint, family or individual counseling?        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- When used or disclosed by the covered entity to    |   |   |   |
|   |   |   | defend a legal action of other proceeding brought by  |   |   |   |
|   |   |   | the individual?                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If the authorization is signed by a personal       |   |   |   |
|   |   |   | representative with authority to act?                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | If your organization requests authorization for its   |   |   |   |
| 6 |   |   | own use or disclosure of PHI that it maintains, does  |   |   |   |
| \ |   |   | the authorization contain all the following elements: |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| . |   |   | \- Organization will not condition treatment,         |   |   |   |
|   |   |   | payment, enrollment in a health plan, or eligibility  |   |   |   |
|   |   |   | for benefits on authorization for use and disclosure? |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Description of each purpose of the use or          |   |   |   |
|   |   |   | disclosure?                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Statement that the individual may inspect or copy  |   |   |   |
|   |   |   | the PHI to be used or disclosed?                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Statement that the individual may refuse to sign   |   |   |   |
|   |   |   | the authorization?                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Statement if the use or disclosure will result in  |   |   |   |
|   |   |   | direct or indirect remuneration to the covered entity |   |   |   |
|   |   |   | from a third party?                                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Does your organization have a policy regarding        |   |   |   |
| 7 |   |   | mandatory disclosure of PHI to:                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- individual upon individual's request?              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- HHS in connection with enforcement and compliance  |   |   |   |
|   |   |   | actions?                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- as otherwise required by law?                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Is your organization aware of the permissible uses    |   |   |   |
| 8 |   |   | and disclosures of PHI without patient authorization  |   |   |   |
| \ |   |   | for?                                                  |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Public Health                                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Reporting Abuse, Neglect or Domestic Violence      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Health oversight activities                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Judicial and administrative proceedings            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Law enforcement                                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- When the patient is deceased                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Research                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Emergency circumstances                            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Special categories                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 8 |   |   | Does your organization permit the right to revoke an  |   |   |   |
| 9 |   |   | authorization EXCEPT:                                 |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If the organization has already taken action in    |   |   |   |
|   |   |   | reliance on the authorization?                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If authorization was obtained as a condition of    |   |   |   |
|   |   |   | obtaining insurance and a law provides the insurer    |   |   |   |
|   |   |   | the right to contest a claim under the policy?        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization review authorizations and      |   |   |   |
| 0 |   |   | consider authorizations ineffective if:               |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The expiration date has passed or the covered      |   |   |   |
|   |   |   | entity knew the expiration event had occurred?        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The form has not been filled out completely?       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The authorization is known to have been revoked?   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The form lacks any required element?               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- It is a compound authorization not allowed by the  |   |   |   |
|   |   |   | regulations?                                          |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- The organization knows that any material on the    |   |   |   |
|   |   |   | form is false?                                        |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Do you allow the provision of treatment, payment,     |   |   |   |
| 1 |   |   | enrollment in a health plan, or eligibility for       |   |   |   |
| \ |   |   | benefits on the execution of an authorization only    |   |   |   |
| . |   |   | when the treatment is research related?               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization have policies for              |   |   |   |
| 2 |   |   | unemancipated minors that comport with both the       |   |   |   |
| \ |   |   | privacy regulations and state law?                    |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization have a policy regarding the    |   |   |   |
| 3 |   |   | use and disclosure of demographic and PHI for         |   |   |   |
| \ |   |   | marketing and fundraising purposes?                   |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Do the marketing materials:                           |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Identify that the come form the covered entity?    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- State whether the entity receives compensation     |   |   |   |
|   |   |   | from a third party for the marketing materials?       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- If not a newsletter, permit the individual to opt  |   |   |   |
|   |   |   | out of receiving further materials?                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization obtain authorization for any   |   |   |   |
| 5 |   |   | other marketing using PHI?                            |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | If your organization uses PHI for fundraising         |   |   |   |
| 6 |   |   | purposes without consent, does it use only the        |   |   |   |
| \ |   |   | patient's name, address and other demographic         |   |   |   |
| . |   |   | information and the dates of treatment?               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization permit the patient to opt out  |   |   |   |
| 7 |   |   | of receiving fundraising materials?                   |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization obtain patient authorization   |   |   |   |
| 8 |   |   | for other fundraising efforts?                        |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 9 |   |   | Does your organization have policies in place         |   |   |   |
| 9 |   |   | regarding disclosure of PHI to business associates?   |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization conducted a review to determine |   |   |   |
| 0 |   |   | who their business associates are as defined by       |   |   |   |
| 0 |   |   | HIPAA?                                                |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Are the HIPAA required provisions detailed in all     |   |   |   |
| 0 |   |   | contracts with your business associates, including    |   |   |   |
| 1 |   |   | that the Business Associate:                          |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will not use or further disclose the information   |   |   |   |
|   |   |   | other than as permitted or required by the contract?  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will not use or further disclose the information   |   |   |   |
|   |   |   | in a manner that would violate the requirements of    |   |   |   |
|   |   |   | the privacy regulations, if done by the covered       |   |   |   |
|   |   |   | entity?                                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will use appropriate safeguards to prevent use or  |   |   |   |
|   |   |   | disclosure of the information other than as provided  |   |   |   |
|   |   |   | for by its contract?                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will report to the covered entity any use or       |   |   |   |
|   |   |   | disclosure of information not provided for by the     |   |   |   |
|   |   |   | contract of which it becomes aware?                   |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will ensure that any subcontractors or agents to   |   |   |   |
|   |   |   | whom it provides protected health information         |   |   |   |
|   |   |   | received from the covered entity agree to the same    |   |   |   |
|   |   |   | restrictions and conditions that apply to the         |   |   |   |
|   |   |   | Business Associate with respect to such information?  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will make available PHI to the individual in       |   |   |   |
|   |   |   | accordance with the individual's right of access?     |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will make its books and records relating to the    |   |   |   |
|   |   |   | use of PHI received from the covered entity available |   |   |   |
|   |   |   | to the Secretary of HHS for purposes of determining   |   |   |   |
|   |   |   | compliance?                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Will, at the termination of the contract, return   |   |   |   |
|   |   |   | or destroy all PHI received from, or created or       |   |   |   |
|   |   |   | received by the Business Associate on behalf of the   |   |   |   |
|   |   |   | covered entity that the Business Associate still      |   |   |   |
|   |   |   | maintains in any form and retain no copies of such    |   |   |   |
|   |   |   | information?                                          |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Have all of your business associates signed these     |   |   |   |
| 0 |   |   | contracts?                                            |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is there a protocol for your organization to follow   |   |   |   |
| 0 |   |   | when there is a breach of contract by a business      |   |   |   |
| 3 |   |   | associate?                                            |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization developed a policy and          |   |   |   |
| 0 |   |   | procedure to remove specific identifiers and create   |   |   |   |
| 4 |   |   | "de-identified" information?                          |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If so, does the policy or procedure include how       |   |   |   |
| 0 |   |   | de-identified information should be disseminated?     |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization's policy permit an individual  |   |   |   |
| 0 |   |   | to request access to inspect or to copy PHI?          |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If your organization requires the request to be in    |   |   |   |
| 0 |   |   | writing, do you inform the individual of the          |   |   |   |
| 7 |   |   | requirement?                                          |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization provide access in the form or  |   |   |   |
| 0 |   |   | format requested if possible?                         |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization provide only a summary or      |   |   |   |
| 0 |   |   | provide an explanation if the individual agrees to    |   |   |   |
| 9 |   |   | such a summary or explanation in advance?             |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization provide access in a timely     |   |   |   |
| 1 |   |   | manner?                                               |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If your organization does not have the information,   |   |   |   |
| 1 |   |   | do you inform the individual of where they might      |   |   |   |
| 1 |   |   | obtain the information?                               |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization document and keep for six      |   |   |   |
| 1 |   |   | years the designated record sets subject to access by |   |   |   |
| 2 |   |   | the individual and the titles of the persons or       |   |   |   |
| \ |   |   | offices responsible for receiving and processing      |   |   |   |
| . |   |   | requests for access?                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | For uses and disclosures required by law, have you    |   |   |   |
| 1 |   |   | determined whether state law limits the disclosure    |   |   |   |
| 3 |   |   | otherwise allowed by the privacy regulations?         |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization verify the identity of the     |   |   |   |
| 1 |   |   | person requesting PHI?                                |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Do you authenticate subpoenas and other similar       |   |   |   |
| 1 |   |   | documents requesting PHI?                             |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Do you ensure that any requests for PHI also comply   |   |   |   |
| 1 |   |   | with the Federal Confidentiality Regulations or the   |   |   |   |
| 6 |   |   | State Mental Health Regulations?                      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Do you require proof of identification from officials |   |   |   |
| 1 |   |   | or official sources, such as badges, id cards,        |   |   |   |
| 7 |   |   | requests on official government letterhead etc.?      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If your organization charges a fee for records, is it |   |   |   |
| 1 |   |   | reasonable and cost-based?                            |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Did the individual agree to the fee?                  |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have and enforce a sanction    |   |   |   |
| 2 |   |   | policy for those members of your organization who     |   |   |   |
| 0 |   |   | breach confidentiality?                               |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| S |   |   |                                                       |   |   |   |
| e |   |   |                                                       |   |   |   |
| c |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| o |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| I |   |   |                                                       |   |   |   |
| I |   |   |                                                       |   |   |   |
| I |   |   |                                                       |   |   |   |
| - |   |   |                                                       |   |   |   |
| - |   |   |                                                       |   |   |   |
| S |   |   |                                                       |   |   |   |
| e |   |   |                                                       |   |   |   |
| c |   |   |                                                       |   |   |   |
| u |   |   |                                                       |   |   |   |
| r |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| y |   |   |                                                       |   |   |   |
| S |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| d |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| r |   |   |                                                       |   |   |   |
| d |   |   |                                                       |   |   |   |
| s |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| # |   |   | *Overall Administrative Security Assessment*          |   |   |   |
|   |   |   |                                                       |   |   |   |
| A |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
|   |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization identified areas of concerns    |   |   |   |
| 2 |   |   | through analysis of different scenarios where         |   |   |   |
| 1 |   |   | information may be exposed, both intentionally and    |   |   |   |
| \ |   |   | unintentionally?                                      |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a formal written security |   |   |   |
| 2 |   |   | program/policy?                                       |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization conducted a review of current   |   |   |   |
| 2 |   |   | organizational practices regarding security and       |   |   |   |
| 3 |   |   | privacy of information?                               |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization identified possible threats to  |   |   |   |
| 2 |   |   | information, such as disgruntled employees, hackers,  |   |   |   |
| 4 |   |   | competitors, etc?                                     |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization determined important            |   |   |   |
| 2 |   |   | information to be protected in both paper and         |   |   |   |
| 5 |   |   | electronic form and where this information is         |   |   |   |
| \ |   |   | located?                                              |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization assessed probability of threats |   |   |   |
| 2 |   |   | and degree of risk if threat does occur?              |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization assigned security               |   |   |   |
| 2 |   |   | responsibility to a specific individual or            |   |   |   |
| 7 |   |   | organization in writing?                              |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   | ***Technical Security***                              |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| B |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | How does your organization authenticate users?        |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Context based access                               |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Role based access                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- User based access                                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Are audit procedures in place to document security    |   |   |   |
| 2 |   |   | access control violations?                            |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a procedure for handling  |   |   |   |
| 3 |   |   | natural and man-made disasters?                       |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization's network connect to the       |   |   |   |
| 3 |   |   | Internet?                                             |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is encryption used on any software or hardware in     |   |   |   |
| 3 |   |   | your organization?                                    |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization use digital signatures?        |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a policy regarding        |   |   |   |
| 3 |   |   | digital signatures that meets OASA requirements under |   |   |   |
| 4 |   |   | 77 Ill. Admin. Code 2060.325, including:              |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -digital signatures must also include the initials of |   |   |   |
|   |   |   | the signer's credentials?                             |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -all staff authorized to authenticate records using   |   |   |   |
|   |   |   | digital signatures must be identified in the policy?  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -each user is assigned a unique identifier that is    |   |   |   |
|   |   |   | generated through a confidential access code?         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -the organization has certified in writing that each  |   |   |   |
|   |   |   | identifier is kept confidential?                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | -each user has certified in writing that he or she is |   |   |   |
|   |   |   | the only person with user access to the identifier    |   |   |   |
|   |   |   | and the only person authorized to use the signature   |   |   |   |
|   |   |   | code?                                                 |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization ever used network assessment    |   |   |   |
| 3 |   |   | software for vulnerabilities?                         |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization determined important software   |   |   |   |
| 3 |   |   | applications that must be protected?                  |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization determined important hardware   |   |   |   |
| 3 |   |   | that must be protected?                               |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization reviewed firewall               |   |   |   |
| 3 |   |   | configurations?                                       |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization reviewed security of web        |   |   |   |
| 3 |   |   | servers?                                              |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization conducted a comprehensive       |   |   |   |
| 4 |   |   | review of all operating systems?                      |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization inventoried all currently       |   |   |   |
| 4 |   |   | running programs?                                     |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization compiled a listing of all       |   |   |   |
| 4 |   |   | individuals who have access to the systems?           |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization identified known                |   |   |   |
| 4 |   |   | vulnerabilities in routers, switches, remote access   |   |   |   |
| 3 |   |   | servers, operating systems and specific applications? |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization assessed password usage and     |   |   |   |
| 4 |   |   | strength?                                             |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization defined information security    |   |   |   |
| 4 |   |   | objectives?                                           |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization identified approaches for       |   |   |   |
| 4 |   |   | mitigating risks and threats?                         |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization assessed alternative approaches |   |   |   |
| 4 |   |   | to current practices that expose systems to potential |   |   |   |
| 7 |   |   | threats?                                              |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization selected a unified course of    |   |   |   |
| 4 |   |   | action to eliminate or modify threat?                 |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization implemented selected            |   |   |   |
| 4 |   |   | strategies?                                           |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization conducted testing to ascertain  |   |   |   |
| 5 |   |   | effectiveness of selected strategies?                 |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization maintained and, as necessary,   |   |   |   |
| 5 |   |   | updated all elements of the protection strategy?      |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization implemented procedures for      |   |   |   |
| 5 |   |   | operation in an emergency?                            |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization implemented a disaster recovery |   |   |   |
| 5 |   |   | plan?                                                 |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a data backup plan?       |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Have you installed virus software?                    |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization schedule periodic updates to   |   |   |   |
| 5 |   |   | your virus software?                                  |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   | ***Physical Safeguards***                             |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| C |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is a secure environment provided for all equipment at |   |   |   |
| 5 |   |   | all times?                                            |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| # |   |   | How does your organization authenticate individual    |   |   |   |
|   |   |   | access?                                               |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Password                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Smart card                                         |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Physical characteristics                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Other                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If passwords are used, has your organization          |   |   |   |
| 5 |   |   | determined who may grant passwords or change them and |   |   |   |
| 9 |   |   | under what conditions?                                |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a password system in      |   |   |   |
| 6 |   |   | place that:                                           |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Generates passwords randomly and does not permit   |   |   |   |
|   |   |   | use of social security numbers, nicknames, etc.?      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Generates passwords with at least eight            |   |   |   |
|   |   |   | characters?                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Prohibits sharing of passwords?                    |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Requires users to sign statements concerning use   |   |   |   |
|   |   |   | of the password and that the user will not permit     |   |   |   |
|   |   |   | anyone else to use the password?                      |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- Contains cancellation procedures if the user is no |   |   |   |
|   |   |   | longer authorized to receive access?                  |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does the organization have a visitor sign in/sign out |   |   |   |
| 6 |   |   | policy?                                               |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does the organization escort visitors?                |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Are unauthorized visitors prevented from entering     |   |   |   |
| 6 |   |   | treatment areas?                                      |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Are unauthorized visitors prevented from viewing      |   |   |   |
| 6 |   |   | patients?                                             |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Are security cameras installed?                       |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is access restricted by keys/keycards?                |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is security training provided for all affected staff? |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have policies and procedures   |   |   |   |
| 6 |   |   | governing receipt and removal of hardware and         |   |   |   |
| 8 |   |   | software into and out of the facility?                |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization recorded serial numbers of all  |   |   |   |
| 6 |   |   | computer equipment?                                   |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Has your organization bolted equipment down to        |   |   |   |
| 7 |   |   | prevent theft where necessary?                        |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a policy on portable      |   |   |   |
| 7 |   |   | computers to protect against loss, theft or breach of |   |   |   |
| 1 |   |   | confidentiality?                                      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization require computers to be turned |   |   |   |
| 7 |   |   | off when not in use and/or use screensavers to        |   |   |   |
| 2 |   |   | prevent unauthorized viewing?                         |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization secure disks, cd's and other   |   |   |   |
| 7 |   |   | media as well as hardware?                            |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization protect the computer by        |   |   |   |
| 7 |   |   | maintaining proper temperature, humidity, surge       |   |   |   |
| 4 |   |   | protectors, etc.?                                     |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization perform periodic maintenance   |   |   |   |
| 7 |   |   | on your system?                                       |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization keep maintenance records?      |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization supervise maintenance          |   |   |   |
| 7 |   |   | personnel?                                            |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization prohibit the downloading of    |   |   |   |
| 7 |   |   | unauthorized software, data, access to unauthorized   |   |   |   |
| 8 |   |   | web sites, etc.?                                      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization maintain access authorization  |   |   |   |
| 7 |   |   | records?                                              |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization clear personnel (run           |   |   |   |
| 8 |   |   | background checks, verify references etc.) before     |   |   |   |
| 0 |   |   | granting access?                                      |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have policies in place to      |   |   |   |
| 8 |   |   | minimize data destruction, theft, or breach of        |   |   |   |
| 1 |   |   | confidentiality by terminated employees?              |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have written termination       |   |   |   |
| 8 |   |   | procedures?                                           |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | If so, does your termination procedure require        |   |   |   |
| 8 |   |   | deactivation not only upon termination, but also on   |   |   |   |
| 3 |   |   | long absences, such as disability or maternity leave? |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization's termination procedures       |   |   |   |
| 8 |   |   | include changing combination locks, removal from      |   |   |   |
| 4 |   |   | access lists, removal of user accounts, and turning   |   |   |   |
| \ |   |   | in keys, tokens or cards that allow access?           |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization's termination procedures       |   |   |   |
| 8 |   |   | require a supervisor to review departing employees'   |   |   |   |
| 5 |   |   | continuing duties to maintain confidentiality?        |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a policy on facsimile     |   |   |   |
| 8 |   |   | transmission of PHI?                                  |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization limit facsimile transmissions  |   |   |   |
| 8 |   |   | to certain specific parameters?                       |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization take precautions to ensure     |   |   |   |
| 8 |   |   | that the fax is received by the proper recipient?     |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have a confidentiality notice  |   |   |   |
| 8 |   |   | on the cover sheet?                                   |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization have an e-mail policy?         |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization's policy require making e-mail |   |   |   |
| 9 |   |   | messages concerning PHI part of the treatment record? |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization obtain patient consent to use  |   |   |   |
| 9 |   |   | e-mail containing patient information?                |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization take appropriate measures to   |   |   |   |
| 9 |   |   | protect the integrity and confidentiality of e-mail   |   |   |   |
| 3 |   |   | messages?                                             |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| S |   |   |                                                       |   |   |   |
| e |   |   |                                                       |   |   |   |
| c |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| o |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| I |   |   |                                                       |   |   |   |
| V |   |   |                                                       |   |   |   |
| - |   |   |                                                       |   |   |   |
| - |   |   |                                                       |   |   |   |
| N |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| o |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| l |   |   |                                                       |   |   |   |
| I |   |   |                                                       |   |   |   |
| d |   |   |                                                       |   |   |   |
| e |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| f |   |   |                                                       |   |   |   |
| i |   |   |                                                       |   |   |   |
| e |   |   |                                                       |   |   |   |
| r |   |   |                                                       |   |   |   |
| s |   |   |                                                       |   |   |   |
| S |   |   |                                                       |   |   |   |
| t |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| n |   |   |                                                       |   |   |   |
| d |   |   |                                                       |   |   |   |
| a |   |   |                                                       |   |   |   |
| r |   |   |                                                       |   |   |   |
| d |   |   |                                                       |   |   |   |
| s |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   | ***Providers***                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| A |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization currently perform provider     |   |   |   |
| 9 |   |   | enrollment functions?                                 |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does the length of your current provider number       |   |   |   |
| 9 |   |   | format equal or exceed the proposed national provider |   |   |   |
| 5 |   |   | identifier?                                           |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is your current number alphanumeric?                  |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Is there excess space (filler space) in systems       |   |   |   |
| 9 |   |   | referencing or maintaining provider information?      |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   | ***Employers***                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| B |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 1 |   |   | Does your organization currently require an employer  |   |   |   |
| 9 |   |   | identifier for any process or procedure?              |   |   |   |
| 8 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| # |   |   | ***Health Plans***                                    |   |   |   |
|   |   |   |                                                       |   |   |   |
| C |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
|   |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| # |   |   | Does your organization currently require a health     |   |   |   |
|   |   |   | plan identifier for any process or procedure?         |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| 9 |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| * |   |   | ***Code Set Standards***                              |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| D |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
| * |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently accept or support    |   |   |   |
| 0 |   |   | the following code set?                               |   |   |   |
| 0 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- ICD 9 CM                                           |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- CPT 4                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- HCPCS                                              |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- CDT                                                |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
|   |   |   | \- NDC                                                |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization rely on "local" coding schemes |   |   |   |
| 0 |   |   | to conduct business?                                  |   |   |   |
| 1 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| # |   |   | ***Section V - Transaction Standards***               |   |   |   |
|   |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently send or receive data |   |   |   |
| 0 |   |   | in ASC X12 formats?                                   |   |   |   |
| 2 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently have a translator on |   |   |   |
| 0 |   |   | site?                                                 |   |   |   |
| 3 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently use a                |   |   |   |
| 0 |   |   | switch/clearinghouse for translator/routing services? |   |   |   |
| 4 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently send or receive data |   |   |   |
| 0 |   |   | in NCPDP format?                                      |   |   |   |
| 5 |   |   |                                                       |   |   |   |
| \ |   |   | What version?                                         |   |   |   |
| . |   |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently support NCPDP Batch  |   |   |   |
| 0 |   |   | Transaction Standard V 1.0?                           |   |   |   |
| 6 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+
| 2 |   |   | Does your organization currently send or receive data |   |   |   |
| 0 |   |   | in HL7 format?                                        |   |   |   |
| 7 |   |   |                                                       |   |   |   |
| \ |   |   |                                                       |   |   |   |
| . |   |   |                                                       |   |   |   |
+---+---+---+-------------------------------------------------------+---+---+---+

\* This checklist is based on the Privacy Regulation published in the
Federal Register December 2000. It does not include modifications to the
Rule proposed in the Notice of Public Rule Making (NPRM) published on
March 27, 2002. It is not intended to be a comprehensive list nor to
imply legal advice.