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HIPAA Help: Your Top Compliance Questions Answered

January 29, 2025

Managing HIPAA compliance for your practice can be challenging. Given the overwhelming number of laws, requirements, and procedures to navigate, you likely have questions about ensuring compliance.

Other practices likely have the same questions as yours. 

Learn more about the most common questions healthcare practices have and how you can ensure compliance. 

 

Who Needs to Do HIPAA Training?

One of the most important HIPAA requirements is making sure staff members complete training. When facing a HIPAA investigation or audit, the Office for Civil Rights (OCR) will ask for documentation proving your practice has been properly trained. 

However, many questions might arise around this, including: How often should staff members train? How long should I keep training records? Who in my practice has to complete HIPAA training? 

First, HIPAA training is required for all staff that have access to Protected Health Information (PHI). PHI includes information like names, Social Security numbers, medical records, and more. Staff with access to sensitive data need to understand the foundation of HIPAA and how thorough data management protects patients. As staff members learn about vital skills such as breach management, compliant patient communication, and handling sensitive information, they become better equipped to manage PHI. 

Documentation of this training is required for each individual, such as each staff member receiving a completion certificate. This completion certification, or whatever proof that training has been completed, must be saved for at least six years. When being investigated, the OCR can and will ask for multiple years of training proof, so ensure your training program documentation is properly organized.

This training needs to be completed at least annually, and it is recommended that new staff be trained as soon as possible before handling PHI. Staff should also be retrained should a breach occur, refreshing staff on proper procedures. 

What is a Business Associate Agreement? 

When entrusted with PHI, it is crucial that any third-party vendors working with your practice implement appropriate safeguards to protect sensitive data.

This is where a Business Associate Agreement (BAA) comes in. The BAA is a document that holds both parties responsible for the protection of PHI. This document includes what PHI is defined as and how both parties have to uphold its protection. 

HIPAA requires this document to be signed by any Business Associate (BA) with access to PHI. Some common examples of BAs include shredding companies, billing companies, and more. 

If your BA doesn’t want to sign this agreement, that’s a bad sign, and it’s recommended that your practice works with another vendor. 

The OCR also recently proposed strengthened requirements for BAs. This would require businesses work with a cybersecurity expert to prove adequate safeguards for patient data are in place. 

What Should I Do with Patient Consent Forms? 

The HIPAA Authorization for Use or Disclosure of Health Information Patient Consent Form must be provided to the patient before you can work with them.

Consent forms allow patients to understand and authorize how their health information is shared. This includes granting access to specific individuals. 

Patients can decline to sign this form and still be treated by the practice, but it must be noted in their records. 

It is also always best practice to review these consent forms with patients every three years, ensuring that the information is still current. 

What’s Next? 

From staff training and business associate agreements to patient consent forms, staying HIPAA compliant requires attention to detail. Smart software solutions with expert teams and simplified compliance can help alleviate this burden and allow you to easily check your compliance status.

HIPAA compliance may seem daunting, but by taking these steps and utilizing the right tools, you can protect your practice and your patients. 

Ready to learn more? Watch our latest webinar, which addresses even more of the top questions healthcare professionals have when it comes to healthcare compliance. 

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September 21, 2026   The HHS Office for Civil Rights (OCR) has announced its biggest HIPAA settlement of the year, reaching nearly a million dollars.  Ambry, a genetic testing and clinical genomics provider based in Aliso Viejo, California is at the center of this enforcement. A settlement was reached over a 2020 phishing attack that exposed the Protected Health Information (PHI) of more than 225,000 individuals. This settlement is a clear reminder that even large organizations trip up on HIPAA requirements.    What happened In January 2020, an employee email account at Ambry was compromised through a phishing attack.  The breach potentially exposed a wide range of PHI, including names, addresses, dates of birth, Social Security Numbers, financial details, and more. Ambry reported the breach to OCR in March 2020, which kicked off the investigation.    Where OCR found gaps OCR’s investigation identified several HIPAA Security Rule gaps, including: No accurate, thorough risk analysis of risks and vulnerabilities to ePHI No process for cutting off access to ePHI when an employee left or no longer needed access No unique user IDs for tracking who was accessing ePHI systems These are baseline HIPAA requirements that every Covered Entity and Business Associate is expected to have in place.   The settlement terms Ambry paid $700,000 and agreed to a two-year corrective action plan, under which it must: Complete a thorough risk analysis of ePHI confidentiality, integrity, and availability Build and execute a risk management plan addressing what that analysis turns up Review and update Security Rule policies and procedures as needed Implement unique user identification across all ePHI systems Train the whole workforce on those updated policies The takeaway for practices When 90% of healthcare hacks start with a successful phishing attempt, it’s key your team is aware of the role they play to keep data safe. Every practice should ask; Do we know exactly where our ePHI lives and how it moves through our systems? Do we have a current, documented risk analysis? Would we catch it fast if a former employee’s access wasn’t revoked? Looking for the first step of addressing these gaps? Meet with one of our compliance experts to see where you currently stand. 

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