Privacy Act and HIPAA Clinical Refresher

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Under HIPAA, a covered entity (CE) is defined as:

All of the above Under HIPAA, a CE is a health plan, a health care clearinghouse, or a health care provider engaged in standard electronic transactions covered by HIPAA.

The minimum necessary standard:

All of the above The minimum necessary standard limits uses, disclosures, and requests for PHI to the minimum necessary amount of PHI needed to carry out the intended purposes of the use or disclosure. The minimum necessary standard does not apply to disclosures to, or requests by, a health care provider for treatment purposes. It also does not apply to uses or disclosures made to the individual or pursuant to the individual’s authorization.

Which of the following would be considered PHI?

An individual’s first and last name and the medical diagnosis in a physician’s progress report

The HIPAA Privacy Rule applies to which of the following?

All of the above The HIPAA Privacy Rule applies to PHI that is transmitted or maintained by a covered entity or a business associate in any form or medium.

Which of the following statements about the HIPAA Security Rule are true?

All of the above The HIPAA Security Rule: Established a national set of standards for the protection of PHI that is created, received, maintained, or transmitted in electronic media by a HIPAA CE or BA; protects ePHI; and addresses three types of safeguards – administrative, technical and physical – that must be in place to secure individuals’ ePHI.

The HIPAA Security Rule applies to which of the following:

PHI transmitted electronically

Which of the following are fundamental objectives of information security?

All of the above Confidentiality, Integrity, and Availability are the fundamental objectives of health information security and the HIPAA Security Rule requires covered entities and business associates to protect against threats and hazards to these objectives.

Technical safeguards are:

Information technology and the associated policies and procedures that are used to protect and control access to ePHI

If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with the:

All of the above If an individual believes that a DoD CE is not complying with HIPAA he or she may file a complaint with the DHA Privacy Office, HHS Secretary, and/or the MTF HIPAA Privacy Officer.

Which of the following are categories for punishing violations of federal health care laws?

All of the above The three main categories of punishment for violating federal health care laws include: criminal penalties, civil money penalties, and sanctions.

Which HHS Office is charged with protecting an individual patient’s health information privacy and security through the enforcement of HIPAA?

Office for Civil Rights (OCR)

A covered entity (CE) must have an established complaint process.


Which of the following are examples of personally identifiable information (PII)?

All of the above PII means information that can be linked to a specific individual and may include the following: Social Security Number; DoD identification number; home address; home telephone; date of birth (year included); personal medical information; or personal/private information (e.g., an individual’s financial data).

The e-Government Act promotes the use of electronic government services by the public and improves the use of information technology in the government.


A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:

All of the above A SORN serves as a notice to the public about a system of records and must: Specify routine uses (how the information will be used), be republished if a new routine use is created, and be provided to OMB and Congress and published in the Federal Register before the system is operational.

Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.


A breach as defined by the DoD is broader than a HIPAA breach (or breach defined by HHS).


Which of the following are common causes of breaches?

All of the above Breaches are commonly associated with human error at the hands of a workforce member. Improper disposal of electronic media devices containing PHI or PII is also a common cause of breaches. Theft and intentional unauthorized access to PHI and PII are also among the most common causes of privacy and security breaches. Another common cause of a breach includes lost or stolen electronic media devices containing PHI and PII such as laptop computers, smartphones and USB storage drives. Lost or stolen paper records containing PHI or PII also are a common cause of breaches.

Which of the following are breach prevention best practices?

All of the above You can help prevent a breach by accessing only the minimum amount of PHI/PII necessary and by promptly retrieving documents containing PHI/PII from the printer. You should always logoff or lock your workstation when it is unattended for any length of time.

When must a breach be reported to the U.S. Computer Emergency Readiness Team?

Within 1 hour of discovery

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