HIPAA Security Incident Procedures (45 CFR 164.308(a)(6))
Required standard for identifying and responding to security incidents involving ePHI, with mitigation, documentation, and outcome tracking.
Primary source
45 CFR 164.308(a)(6) — eCFR →https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.308#p-164.308(a)(6)
Verified May 23, 2026 · This is the authoritative regulator URL. The summary below is a research aid; the linked source controls.
45 CFR 164.308(a)(6)(6)) requires a covered entity to implement policies and procedures to address security incidents — the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information, or interference with system operations in an information system.
Required specification: response and reporting — identify and respond to suspected or known security incidents; mitigate, to the extent practicable, harmful effects of security incidents known to the entity; and document security incidents and their outcomes.
Not every security incident is a breach under the Breach Notification Rule. The incident procedures standard is the upstream gate: detect, contain, investigate, and document. A subset of incidents involving unsecured PHI will then trigger the breach risk assessment at 164.402.
Practical baseline: a written incident response plan, defined incident severity tiers, a 24-hour internal escalation contract, and a quarterly tabletop exercise. The investigation outcome plus mitigation actions belong in the documentation maintained for six years.
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Related across the archive
- RegulationHIPAA Administrative Safeguards (45 CFR 164.308)Nine standards covering security management, workforce security, training, contingency planning, incident procedures, evaluation, and business associate contracts.
- RegulationHIPAA Security Risk Analysis Standard (45 CFR 164.308(a)(1)(ii)(A))Required implementation specification: conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.
- RegulationHIPAA Breach Notification Rule Overview (45 CFR 164.400-414)When unsecured PHI is accessed, used, or disclosed in a manner not permitted, the entity must follow individual, HHS, and (in some cases) media notification requirements within defined timelines.
- RegulationHIPAA Security Access Control (45 CFR 164.312(a))Technical policies and procedures for systems containing ePHI to allow access only to those granted access rights, with required specifications for unique user identification and emergency access.
- ComplianceHIPAA Contingency Plan Template — 45 CFR § 164.308(a)(7)2026 HIPAA contingency plan template — 45 CFR § 164.308(a)(7) data backup, DRP, emergency mode, testing, and applications/data criticality analysis.
- SRAChange Healthcare Ransomware: What Small Practices Took AwayThe February 2024 Change Healthcare cyberattack, what HHS and UnitedHealth Group disclosed, and the small-practice lessons about clearinghouse concentration risk, contingency planning, and the Security Rule's information system activity review.
- GlossaryAccess ControlsTechnical policies and procedures that allow only authorized persons or software programs to access ePHI.
- BillingBusiness Associate Agreement Checklist for Small PracticesA working checklist for small practices to identify which vendors need a Business Associate Agreement, what clauses the BAA must contain, and how to track them.
Last reviewed May 23, 2026 · Citation verified May 23, 2026
Research aid, not legal advice. This summary is an administrative research aid prepared by D3rx. It does not certify compliance, provide legal advice, replace counsel, or guarantee an audit outcome. For authoritative regulatory text follow the primary source link at the top of this page. The practice remains responsible for reviewing, adopting, and maintaining its compliance program.