HIPAA SA-3.2: Workforce Clearance Procedures for ePHI Access
Controlling who accesses your electronic protected health information (ePHI) is foundational to HIPAA compliance. SA-3.2 requires you to establish clear procedures that verify access decisions are appropriate before granting workforce members ePHI permissions. Without documented clearance procedures, you risk unauthorized access and compliance violations.
What this means
SA-3.2 mandates that your organization create and maintain documented procedures to assess whether each workforce member's requested access to ePHI is justified by their role and responsibilities. This means evaluating access requests against job functions, conducting background reviews where applicable, and documenting approval decisions before granting credentials or system permissions.
How to comply
- 1.Document a workforce clearance procedure that defines the approval process for ePHI access requests
- 2.Establish clear job function definitions that link roles to required ePHI access levels
- 3.Require managers or designated approvers to review and authorize access requests before implementation
- 4.Conduct background checks or vetting appropriate to the access level being granted
- 5.Maintain written records of all clearance decisions with dates and approver signatures
- 6.Review and update clearance procedures annually or when organizational structure changes
- 7.Implement a process to revoke access when workforce members change roles or leave the organization
Evidence auditors look for
- Access request forms signed by authorized approvers with clearance justification
- Job description documents mapping roles to ePHI access requirements
- Background check reports or verification documentation for sensitive roles
- Access control matrix showing approved access levels by position
- Audit logs showing access provisioning dates matched to clearance approval dates
- Termination checklists documenting access revocation
- Annual policy review documentation with sign-off from privacy/security leadership
Frequently asked questions
When will FAQs be available?
The FAQ for this control is currently being prepared.
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