Under HIPAA, Business Associates (BAs) must implement administrative, physical, and technical safeguards for any PHI they create, receive, maintain, or transmit.
Unfortunately, it’s not enough to do the right things; you have to prove it.
And that proof starts with written policies and documented procedures, a lot of them.
HIPAA expects you to:
- Define your security and privacy practices
- Train your team on them
- Enforce them
- Update them as your systems change
Let’s look at what that actually means in practice.
Core Security & Privacy Policies Every Business Associate Must Have
HIPAA doesn’t prescribe exact document names, but it requires the implementation of safeguards, and expects policies and procedures to match those safeguards. Here’s a consolidated list of what your HIPAA policy set should include as a Business Associate:
Administrative Safeguards
These govern how your team is structured, trained, and managed.
Must-Have Policies:
- HIPAA Security & Privacy Overview Policy
High-level policy that affirms your organization's commitment to HIPAA compliance.
- Workforce Security Policy
Defines how access to PHI is granted, reviewed, and revoked.
- Security Awareness & Training Policy
Requires regular training on HIPAA, phishing, password hygiene, and incident reporting.
- Sanction Policy
Outlines disciplinary actions for employees who violate HIPAA policies.
- Risk Analysis & Risk Management Policy
Documents how you identify and address risks to PHI (required under 45 CFR §164.308(a)(1)).
- Incident Response & Breach Notification Policy
Defines how to detect, report, document, and respond to incidents and how to notify covered entities and HHS of breaches.
- Contingency Plan / Disaster Recovery Policy
Ensures PHI can be recovered after system failure or disaster (includes data backup and emergency mode operations).
- Workstation Use & Security Policy
Clarifies how workstations (laptops, desktops) should be secured when accessing PHI.
- Device & Media Control Policy
Details how devices that access PHI are tracked, wiped, and disposed of securely.
Technical Safeguards
These policies focus on controlling access, securing data, and detecting misuse.
Must-Have Policies:
- Access Control Policy
Describes how unique user IDs, session timeouts, and access restrictions are enforced.
- Authentication Policy
Requires secure login credentials and, ideally, multi-factor authentication for systems accessing PHI.
- Encryption Policy
Establishes encryption standards for data at rest and in transit.
- Audit Logging & Monitoring Policy
Ensures systems generate logs for PHI access and that logs are reviewed regularly.
- Transmission Security Policy
Specifies protocols to secure PHI over networks (e.g., HTTPS, TLS, VPN).
Physical Safeguards
These apply whether you host your app in the cloud or access PHI on employee laptops.
Must-Have Policies:
- Facility Access Control Policy
Regulates who can enter areas where PHI is stored or accessed.
- Workstation Security Policy
Protects physical devices from unauthorized access or theft.
- Mobile Device Management Policy
Governs laptops, phones, and tablets that access PHI, must support remote wipe, encryption, etc.
Organizational Requirements: Managing Risk Upstream and Downstream
You don’t operate in a vacuum. HIPAA expects you to manage risk in your vendor ecosystem, too.
Must-Have Policies:
- Business Associate Agreement (BAA) Management Policy
Document how you handle BAAs with your clients and downstream vendors.
- Third-Party Vendor Risk Management Policy
Ensures vendors handling PHI are evaluated and monitored for HIPAA compliance.
Optional But Strongly Recommended
- HIPAA Documentation & Version Control Policy
Describes how policies are updated and how documentation changes are logged.
- Minimum Necessary Access Policy
Ensures employees only access the PHI required to do their jobs.
- Data Retention & Disposal Policy
Clarifies how long PHI is retained and how it is securely destroyed.
- Remote Work & BYOD Policy
Applies to remote teams and personal devices, common in startups.
- AI Use & Data Protection Policy
Defines how artificial intelligence tools (including large language models) can and cannot be used in contexts involving PHI.
Let Security Ideals Write, Review, or Launch It All for You
Not sure where to start? Already behind on documentation? Security Ideals helps HIPAA-regulated SaaS companies like yours go from zero to compliant with startup-friendly solutions.
We offer:
Policy Toolkit for BAs
Pre-written, audit-ready HIPAA policies tailored to cloud-first startups.
Compliance Jumpstart Packages
We’ll walk your team through the must-haves, customize docs, and prep you for customer security reviews.
Security Architecture Reviews
Make sure your AWS/GCP setup actually aligns with your policies.
Pre-Audit & Client Questionnaire Support
From health system RFPs to third-party audits, we’ve got your back.
Flexible packages for every stage and every budget
Book a free discovery call today and we’ll help you build a HIPAA program that doesn’t slow you down.
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