Step 1 – Application and Scope
Share your organization details, PHI flows, systems, and locations to set
certification scope.
Step 2 – Gap Assessment and Risk Analysis
Assess current controls against the HIPAA Privacy, Security, and Breach Notification
Rules and complete a formal risk analysis.
Step 3 – Remediation Plan
Prioritize findings, assign owners, define timelines, and document corrective
actions.
Step 4 – Policies and Procedures
Create or update privacy, security, incident response, access control, retention,
and sanction policies, then approve and publish them.
Step 5 – Technical and Physical Safeguards
Implement access controls, encryption, audit logs, secure configuration, backups,
facility controls, and device protections.
Step 6 – Workforce Training and Awareness
Train all staff on HIPAA policies, role-based responsibilities, and breach
reporting, with attendance and attestation records.
Step 7 – Vendor and BAA Management
Identify all business associates, execute and review BAAs, and verify their
safeguards and incident duties.
Step 8 – Documentation and Evidence
Maintain evidence for every requirement including risk assessments, policy versions,
logs, training records, and test results.
Step 9 – Internal Audit and Readiness Review
Validate implementation, test controls, run table-top exercises, and close remaining
gaps.
Step 10 – Independent Audit and Certification Decision
Undergo an external assessment. Address any nonconformities and, once closed,
receive your HIPAA certificate of conformity.
Step 11 – Continuous Monitoring and Annual Surveillance
Perform annual audits, refresh training, review BAAs, retest controls, and follow
the Breach Notification Rule if incidents occur.