Policies and Procedures
Compliance Policies
- 5.1.01 Auditing and Monitoring for Compliance
- 5.1.02 Compliance Training and Education
- 5.1.03 Conflict of Interest
- 5.1.04 Reportable Events Policy
- 5.1.05 Detection of Fraud Waste and Abuse Policy
- 5.1.06 Document Retention and Destruction Policy
- 5.1.07 Gifts and Business Courtesies from Vendors Guidelines
- 5.1.08 Patient Gifts Policy
- 5.1.09 Permitted Waivers of Patient Financial Responsibility Policy
- 5.1.10 Section 1557 – Grievance Policy and Procedure
- 5.1.12 Government Investigations Policy
- 5.1.14 Compliance Exit Interview Policy
- 5.1.15 Emergency Medical Treatment and Active Labor Act (EMTALA) Policy
- 5.1.16 Notice of Non-coverage
- 5.1.17 External Reviews and Audits Policy
- 5.1.19 Identification, Quantification and Repayment of Overpayments Policy
- 5.1.21 Government Exclusion from Participation Policy
- 5.1.22 Risk Assessment Policy
- 5.1.23 Compliance Misconduct and Sanction Policy
- 5.1.24 Management Certification Policy
- 5.1.25 Compliance Disclosure Program Policy
- 5.1.26 Compliance with Anti-Kickback Statute and Stark Law
- 5.1.27 Non-Monetary Compensation (Business Courtesies) and Incidental Medical Staff Benefits Policy
- Whistleblower Protection Policy
- 5.1.01 Auditing and Monitoring for Compliance Procedure
- 5.1.02 Compliance Training and Education Procedure
- 5.1.04 Reportable Events Procedure
- 5.1.05 Detection of Fraud Waste and Abuse
- 5.1.08 Patient Gifts Procedure
- 5.1.12 Government Investigations Procedure
- 5.1.14 Compliance Exit Interview Procedure
- 5.1.16 Notice of Non-Coverage Procedure
- 5.1.17 External Reviews and Audits Procedure
- 5.1.19 Identification, Quantification and Repayment of Overpayments Procedure
- 5.1.21 Government Exclusion from Participation Procedure
- 5.1.22 Risk Assessment Procedure
- 5.1.23 Compliance Misconduct and Sanctions Procedure
- 5.1.24 Management Certifications Procedure
- 5.1.25 Compliance Disclosure Procedure
- 5.1.26 Compliance with Anti-Kickback Statute and Stark Law Procedure
- 5.1.27 Non-Monetary Compensation (Business Courtesies) and Incidental Medical Staff Benefits Procedure
- Compliance and Ethics Program Charter
- HIPAA Glossary
- 5.2.01 Accounting of Disclosures Policy
- 5.2.02 Uses and Disclosures of PHI With and Without Authorization Policy
- 5.2.03 Chief Privacy Officer Policy
- 5.2.05 Direction of Investigation of Privacy Complaints Policy
- 5.2.06 Disclosures by Whistleblowers Policy
- 5.2.07 HIPAA Privacy Training Policy
- 5.2.08 Minimum Necessary for Use and Disclosure Policy
- 5.2.09 Mitigation of Inappropriate Use or Disclosure of Protected Health Information Policy
- 5.2.10 Notice of Privacy Practices Policy
- 5.2.11 Patient Request Not to be Listed in Facility Directory Policy
- 5.2.12 Patient Right to Request Privacy Protection for Protected Health Information Policy
- 5.2.13 Validation-of-Patient-Authorization Policy
- 5.2.14 Request-for-Restrictions-on-Uses-and-Disclosures-of-PHI Policy
- 5.2.15 Safeguards for Sensitive Information, Protected Health Information and Electronic Protected Health Information Policy
- 5.2.16 HIPAA Business Associate Agreement Policy
- 5.2.17 Permissive-Disclosures-of-PHI-for-Legal-and-Public-Policy-Purposes Policy
- 5.2.18 Patient's Right to Request Amendment to PHI in Medical and Billing Records Policy
- 5.2.19 Fax Policy
- 5.2.20 Patient Right to Access Protected Health Information(PHI) Policy
- 5.2.21 Breach Notification Policy
- 5.2.22 De-Identification Summary Health Information and Limited Data Sets Policy
- 5.2.23 Designated Record Sets Policy
- 5.2.24 Fundraising and the Use of PHI Policy
- 5.2.25 Personal Representatives and Communication with Patient Families Policy
- 5.2.26 Uses and Disclosures of PHI for Marketing Purposes Policy
- 5.2.27 Uses and Disclosures for Treatment, Payment and Healthcare Operations Policy
- 5.2.28 Research Authorization Policy
- 5.2.29 Affiliated Covered Entity Designation Policy
- 5.2.01 Accounting of Disclosures Procedure
- 5.2.02 Uses-and-Disclosures-of PHI-With-and-Without-Authorization Procedure
- 5.2.05 Direction and Investigation of Privacy Complaints Procedure
- 5.2.06 Disclosures by Whistleblowers Procedure
- 5.2.07 HIPAA Privacy Training Procedure
- 5.2.08 Minimum Necessary for Use and Disclosure Procedure
- 5.2.09 Mitigation of Inappropriate Use or Disclosure of Protected Healthcare Information (PHI) Procedure
- 5.2.10 Notice of Privacy Practices Procedure
- 5.2.11 Patient Request Not to be Listed in Facility Directory Procedure
- 5.2.12 Patient Right to Request Privacy Protection for Protected Health Information Procedure
- 5.2.13 Validation-of-Patient-Authorization Proceedure
- 5.2.14 Request-for-Restrictions-on-Uses-and-Disclosures-of-PHI Proceedure
- 5.2.15 Safeguards for Sensitive Information Protected Health Information and Electronic Health Information Procedure
- 5.2.16 HIPAA Business Associate Agreement Procedure
- 5.2.17 Permissive Disclosures of PHI for Legal and Public Policy Purposes Procedure
- 5.2.18 Patients Right to Request Amendments of their Protected Health Information Procedure
- 5.2.19 Faxing (facsimile) PHI Procedure
- 5.2.20 Patient Right to Access Protected Health Information(PHI) Procedure
- 5.2.22 De-Identification Summary Health Information and Limited Data Sets Procedure
- 5.2.23 Designated Record Sets Procedure
- 5.2.24 Fundraising and the Use of PHI Procedure
- 5.2.25 Personal Representatives and Communication with Patient Families Procedure
- 5.2.26 Uses and Disclosures of PHI for Marketing Purposes Procedure
- 5.2.27 Uses and Disclosures for Treatment, Payment and HealthCare Operations Procedure
- 5.2.28 Research Authorization Procedure
- 5.2.29 Affiliated Covered Entity Designation Procedure