Toolkit

HIPAA readiness cheat sheet

A one-page summary to work from, not a substitute for the full guide or the official text.

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Who it's for. US covered entities (health plans, clearinghouses, most providers) and their business associates that create, receive, maintain or transmit protected health information.

Scope

  • Covers protected health information, with extra technical safeguards for electronic PHI
  • Many technology vendors become business associates simply by hosting or processing PHI for a covered entity, even without looking at the data
  • Consumer health apps not acting for a covered entity usually fall outside HIPAA, though other laws can still apply

Key requirements

  • Run an accurate, thorough, enterprise-wide risk analysis covering all electronic PHI — the foundation the Security Rule builds on
  • Implement administrative, physical and technical safeguards; assess every 'addressable' specification rather than treating it as optional
  • Apply the minimum necessary standard and keep a current Notice of Privacy Practices
  • Sign a business associate agreement before any business associate creates, receives, maintains or transmits PHI
  • Notify affected individuals without unreasonable delay and within 60 calendar days of discovering a breach; notify HHS, and the media for breaches over 500 people
  • Train the workforce and keep documentation for six years from creation or last effective date

Evidence to gather

  • Risk analysis and risk management plan, kept current
  • Policies and procedures for privacy, security and breach response
  • Business associate agreements, upstream and downstream
  • Workforce training records
  • Access and audit log reviews
  • Breach register and notifications sent
  • Contingency and backup testing evidence

Common gaps

  • Claiming to be 'HIPAA certified' — there is no such government certification
  • A risk analysis that covers only the EHR and leaves out email, backups, laptops and SaaS tools
  • Treating 'addressable' specifications as optional instead of assessing and documenting the decision
  • Assuming the cloud provider's BAA covers everything — configuration and access remain a shared responsibility

This is general educational information, condensed by MajorCyber™ in its own words, not legal, audit or certification advice, and not a compliance assessment, certification or attestation of any kind. It is a starting checklist, not a complete statement of the framework's requirements — confirm anything material against the full HIPAA guide, the official text, or a qualified adviser.

MajorCyber™ · Security Lights the Way majorcyber.org/toolkits/hipaa/