Information Access Management Policy

5. Procedures

1. ACCESS AUTHORIZATION

1.1 The Security Officer shall maintain a Role-Based Access Matrix that maps each job role to the specific systems and access levels required for that role.

1.2 When a new role is created or an existing role's duties change, the supervisor and Security Officer shall review and update the matrix.

1.3 Individual access requests shall be submitted via the Access Change Request Form and must include: the requestor's name and role, the system(s) and specific access level requested, the business justification, and the supervisor's approval.

1.4 The Security Officer shall approve or deny each request based on the role-based access matrix and minimum necessary principles.

2. ACCESS ESTABLISHMENT AND MODIFICATION

2.1 Upon approval, the IT Manager shall provision the requested access within [NUMBER] business days.

2.2 Any modification to access (increase, decrease, or change in scope) shall follow the same request and approval process.

2.3 Emergency or temporary access may be granted by the Security Officer for a defined period not to exceed [NUMBER] days, with full documentation of the business justification.

3. ACCESS REVIEW

3.1 The Security Officer shall conduct a comprehensive review of all access authorizations at least semi-annually to verify that current access is appropriate for each workforce member's role.

3.2 Any access that is no longer necessary shall be revoked promptly.

3.3 The access review results shall be documented and retained.

4. CLEARINGHOUSE ISOLATION

4.1 If [PRACTICE NAME] operates as or includes a healthcare clearinghouse function, the clearinghouse component shall be isolated from other organizational functions. Access to the clearinghouse function shall be separately authorized and controlled.

5. BUSINESS ASSOCIATE ACCESS

5.1 Business associates requiring system-level access to ePHI shall have access governed by the terms of the Business Associate Agreement and limited to the minimum necessary for the contracted service.

5.2 Business associate access shall be tracked in the access authorization log and reviewed at the same frequency as workforce access.

6. Roles & Responsibilities

Security Officer ([SECURITY OFFICER NAME]): Maintains the Role-Based Access Matrix. Reviews and approves access requests. Conducts semi-annual access reviews. Documents all access decisions.

IT Manager/Vendor ([IT CONTACT NAME]): Implements approved access changes in systems. Maintains technical access controls (user accounts, permissions, group policies). Reports any access anomalies.

Supervisors: Determine the access needs for their direct reports. Submit and approve access requests. Notify the Security Officer when access needs change.

All Workforce Members: Use only the access they have been authorized. Do not share access credentials. Report any suspected unauthorized access.

7. Review Schedule

This policy shall be reviewed at least annually. The Role-Based Access Matrix shall be updated whenever new roles are created, existing roles change, or new systems are deployed. Semi-annual access reviews shall be conducted per the Procedures section.

8. Regulatory References

45 CFR § 164.308(a)(4)(i) — Information access management (Required) 45 CFR § 164.308(a)(4)(ii)(A) — Isolating healthcare clearinghouse functions (Required) 45 CFR § 164.308(a)(4)(ii)(B) — Access authorization (Addressable) 45 CFR § 164.308(a)(4)(ii)(C) — Access establishment and modification (Addressable) 45 CFR § 164.502(b) — Minimum necessary standard 45 CFR § 164.514(d) — Minimum necessary requirements for uses and disclosures