This policy is listed for reference only and should be reviewed with your lawyer before implementing them into daily practice. We are not lawyers and are not providing any legal advice. View our legal disclaimer.

Info Access: Management Authorization Policy Guide

Reference: 45 CFR § 164.312(a)(1)
Last Updated: January 26, 2024


Goal: Implement policies and procedures for granting access to electronic protected health information.

The purpose of this policy is to limit the risk of unauthorized disclosures by restricting individual access to the information needed to efficiently meet their obligations.


Procedure: All personnel who need access to ePHI shall be given such access on need to know basis. Access to individual systems shall be given in accordance with the following procedures:

  • The Security Manager will document and maintain access authorization records (Use System Access Log under Forms) in accordance with the following steps:
    • Verify individual access needs to system/information. Request update of Position Description or modify records as needed to indicate required access.
      • Ensure access is limited to personnel whose need-to-know is required for performance of duty.
    • Verify proficiency prior to granting access (if required). If individual needs access to system for training purposes document scheduled training date.
      • Personnel shall not be granted access unless they have proper clearance and have received required training, unless a waiver has been granted.
    • Personnel shall not be granted access unless their need has been approved.
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