HIPAA Compliance

2.1 BAA Requirement

Before providing services to any HIPAA-covered entity, Copper Digital executes a comprehensive Business Associate Agreement that meets all HIPAA and HITECH requirements. Our standard BAA template is provided below.

3.1 Encryption

3.2 Access Controls

• Multi-Factor Authentication (MFA): Required for all user accounts
• Role-Based Access Control (RBAC): Minimum necessary access principles
• Single Sign-On (SSO): Integration with enterprise identity providers
• Session Management: Automatic timeout and concurrent session limits
• API Security: OAuth 2.0 and API key management

3.3 Audit Controls

• Comprehensive logging of all PHI access and modifications
• Real-time security monitoring and alerting
• Immutable audit logs with digital signatures
• Regular log analysis and anomaly detection
• Integration with SIEM systems

3.4 Data Integrity

• Cryptographic hashing for data integrity verification
• Database transaction logging and rollback capabilities
• Regular data consistency checks
• Backup verification and recovery testing

3.5 Transmission Security

• End-to-end encryption for all PHI transmissions
• Secure file transfer protocols (SFTP, HTTPS)
• Network segmentation and VPN requirements
• Regular penetration testing of transmission channels

4.1 Data Center Security

4.2 Workstation Security

• Automatic screen locks and session timeouts
• Encrypted hard drives on all workstations
• Centralized device management and monitoring
• Regular security updates and patch management
• Anti-malware and endpoint protection

4.3 Media Controls

• Secure disposal of PHI-containing media
• Certificate of destruction for all disposed media
• Encrypted removable media when required
• Controlled access to backup media

5.1 Security Organization

5.2 Workforce Training

• Initial Training: Comprehensive HIPAA training for all new employees
• Annual Refresher: Mandatory annual HIPAA compliance training
• Role-Specific Training: Additional training based on PHI access levels
• Incident Response Training: Regular drills and tabletop exercises
• Training Documentation: Completion records maintained for all personnel

5.3 Access Management

• Formal access authorization procedures
• Regular access reviews and certifications
• Immediate access revocation upon employment termination
• Principle of least privilege enforcement
• Segregation of duties for critical functions

5.4 Risk Assessment

• Annual Risk Assessments: Comprehensive evaluation of potential vulnerabilities
• Continuous Monitoring: Ongoing threat detection and analysis
• Third-Party Assessments: Independent security evaluations
• Risk Mitigation Plans: Documented remediation strategies
• Business Impact Analysis: Evaluation of potential breach consequences

5.5 Contingency Planning

• Comprehensive disaster recovery procedures
• Regular backup and restoration testing
• Business continuity planning
• Emergency access procedures
• Recovery time and point objectives defined

6.1 Incident Detection and Response

6.2 Breach Assessment Criteria

We assess whether a security incident constitutes a breach based on:

• Nature and extent of PHI involved
• Person(s) who disclosed PHI and who received it
• Whether PHI was actually viewed or acquired
• Extent to which risk has been mitigated
• Likelihood of re-identification of de-identified information

6.3 Notification Content

All breach notifications include:

• Description of the incident and timeline
• Types of PHI involved in the breach
• Steps taken to investigate and mitigate
• Assessment of risk to individuals
• Contact information for follow-up
• Remediation measures implemented

6.4 Emergency Contact Information

7.1 Current Certifications

7.2 Third-Party Assessments

• Annual HIPAA Risk Assessments: Conducted by certified third-party assessors
• Penetration Testing: Quarterly external and annual internal testing
• Vulnerability Scanning: Continuous automated scanning with monthly reports
• Code Security Reviews: Static and dynamic analysis of all application code
• Compliance Audits: Annual SOC 2 Type II and HITRUST assessments

7.3 AWS HIPAA Eligibility

8.1 Subcontractor Requirements

All subcontractors with potential PHI access must:

• Execute a Business Associate Agreement before PHI access
• Demonstrate equivalent HIPAA compliance measures
• Undergo security assessments and due diligence reviews
• Provide evidence of appropriate insurance coverage
• Participate in incident response procedures
• Submit to regular compliance monitoring

8.2 Current Subcontractors

9.1 Continuous Monitoring

• Real-time Security Monitoring: 24/7 SOC monitoring of all systems
• Automated Compliance Checking: Continuous policy compliance verification
• Behavioral Analytics: Machine learning-based anomaly detection
• Threat Intelligence: Integration with industry threat feeds
• Performance Monitoring: System availability and response time tracking

9.2 Audit Trail Management

9.3 Reporting and Analytics

• Monthly Compliance Reports: Detailed security and compliance metrics
• Quarterly Risk Assessments: Updated risk profiles and mitigation status
• Annual Compliance Certification: Comprehensive compliance attestation
• Incident Response Reports: Detailed analysis of all security incidents
• Custom Reporting: Tailored reports for specific covered entity requirements

While Copper Digital operates as a Business Associate and does not directly interact with patients, we fully support covered entities in fulfilling all HIPAA-required patient rights:

10.1 Right of Access

• Rapid response to covered entity requests for patient data
• Data provided in commonly used, machine-readable formats
• Support for patient-directed data sharing
• Assistance with complex data extraction requests

10.2 Amendment Rights

• Immediate implementation of covered entity-approved amendments
• Tracking and documentation of all amendment requests
• Notification to relevant parties about amendments
• Maintenance of amendment audit trails

10.3 Restriction Requests

• Technical implementation of use and disclosure restrictions
• System controls to enforce restriction requirements
• Regular verification of restriction compliance
• Documentation of all restriction activities

10.4 Accounting of Disclosures

• Comprehensive logging of all PHI disclosures
• Searchable disclosure databases
• Automated accounting report generation
• Six-year disclosure history maintenance

11.1 Documentation

11.2 Training and Support

• Customer Training: HIPAA compliance training for customer staff
• Technical Support: 24/7 support for HIPAA-related technical issues
• Compliance Consulting: Advisory services for complex compliance questions
• Best Practices Sharing: Regular webinars and compliance updates
• Integration Support: Assistance with HIPAA-compliant system integrations