SA-4.3: Information Access Management — Access Establishment and Modification
SA-4.3 requires you to implement formal policies and procedures that govern how user access rights are created, documented, reviewed, and modified across your organization. For covered entities and business associates, this control ensures that access to workstations, transactions, programs, and processes is tightly aligned with your authorization policies. Without systematic access management, you risk unauthorized data exposure and compliance violations.
What this means
This control mandates that your organization establish a documented process for granting, modifying, and revoking user access based on clearly defined authorization policies. Every change to a user's rights—whether adding, updating, or removing access to workstations, transactions, programs, or processes—must be tracked and approved according to your established procedures. The control requires regular reviews to ensure access remains appropriate and aligned with job responsibilities and organizational needs.
How to comply
- 1.Document your access authorization policies that define who can request, approve, and grant access to each system, workstation, transaction type, and process.
- 2.Establish a formal access request and approval workflow that requires documented justification and manager authorization before granting any access.
- 3.Create and maintain an access matrix or inventory that maps users to their authorized workstations, transactions, programs, and processes.
- 4.Implement a change management process that requires approval and documentation for all access modifications, including role changes and terminations.
- 5.Conduct periodic access reviews (at least quarterly or annually depending on your risk assessment) to verify that current access rights remain appropriate.
- 6.Document all access establishment, modification, and revocation activities with timestamps, approvers, and justifications for audit purposes.
- 7.Ensure access is revoked immediately upon user termination, role change, or when no longer operationally necessary.
Evidence auditors look for
- Access authorization policy document that outlines roles, responsibilities, and approval requirements
- Access request forms or tickets with documented approvals showing who requested and who authorized each access grant
- User access inventory or matrix listing all users and their authorized access to workstations, transactions, programs, and processes
- Change control records documenting modifications to user access with dates, approvals, and business justifications
- Quarterly access review reports showing verification that current access rights remain appropriate
- System logs or audit reports demonstrating that access changes were implemented and tracked
- Termination checklists showing access revocation upon employee departure
Frequently asked questions
When will FAQs be available?
The FAQ for this control is currently being prepared.
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