Section 164.308(a)(3)(ii)(B) of the Health Insurance and Portability and Accountability Act (HIPAA) specifies the following standard: "Workforce clearance procedure (Addressable). Implement procedures to determine that the access of a workforce member to electronic protected health information is appropriate."


To provide the necessary information on the procedures used to determine workforce members have the appropriate access to EPHI.


This standard applies to all Medical Center employees.


Eligibility for employment is defined by Medical Center Human Resources Policy 104: Conditions of Employment.

Access to Information Systems is controlled through the Online Access Request Form. As defined in Health System Policy IT-002: Use of Electronic Information and Systems, Supervisors/Managers are responsible for ensuring workforce members receive the appropriate access for their job roles.

In addition, all Medical Center personnel are required to read and sign the Electronic Access Agreement upon hire.

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