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2. What administrative requirements is the University required to implement under HIPAA?

Pursuant to the HIPAA Privacy Regulations, the University, as a Covered Entity, must:

1. Have a Privacy Official;

2. Develop and implement Privacy policies and procedures;

3. Train its workforce (students, volunteers, employees) on HIPAA;

4. Adopt Privacy safeguards to protect PHI;

5. Establish a process for reporting Privacy violations;

6. Adhere to a “no retaliation” policy against individuals who submit Privacy complaints;

7. Impose sanctions for Privacy violations;

8. Mitigate harmful effects of damage from known Privacy violations; and

9. Prohibit waivers of patient Privacy rights.

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