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THIS TRAINING MODULE IS APPROVED FOR NON-COMMERCIAL USE ONLY.  Copyright protected by 
the University of North Carolina at Chapel Hill, 2013-15 
Welcome to the 
HIPAA, Privacy & Security 
Training Module 
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Course Competencies 
During this course you will learn: 
about the Health Insurance Portability and Accountability (“HIPAA”) Privacy 
and Security Rules; 
about the HIPAA identifiers that create protected health information 
(“PHI”); 
how to recognize situations in which confidential and protected health 
information can be mishandled; 
about practical ways to protect the privacy and security of sensitive 
information, including PHI; and 
that employees will be held responsible if they improperly handle 
confidential or protected health information. 
This training module addresses the essential elements of maintaining the 
privacy and security of sensitive information and  
protected health information (PHI) within the University workplace. 
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Forms of Sensitive Information  
It is the responsibility of every employee to  
protect the privacy and security of sensitive information  
in ALL forms. 
printed   
spoken      
electronic 
Sensitive Information exists in various forms… 
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Examples of Sensitive Information 
• Social Security numbers 
• credit card numbers 
• driver’s license numbers 
• personnel information 
• research data 
• computer passwords 
• Individually identifiable health 
information 
The  improper  use  or  disclosure  of sensitive information 
presents the risk of identify theft, invasion of privacy, and can 
cause harm and embarrassment to  students,  faculty,  staff, 
patients, and the University.  Breaches of information privacy 
can  also  result  in  criminal  and  civil  penalties  for  both  the 
University  and  those  individuals  who  improperly  access  or 
disclose  sensitive  information,  as  well  as  disciplinary  action 
for responsible UNC employees. 
Every University employee must  
protect the privacy and security of sensitive information
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HIPAA Privacy & Security Rules 
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law 
designed  to  protect  a  subset  of  Sensitive  Information  known  as protected health 
information (PHI).  
In  2009,  HIPAA  was  expanded  and  strengthened  by  the HITECH Act (Health 
Information  Technology  for  Economic  and  Clinical  Health) In January of 2013, the 
Department  of  Health  and  Human  Services  issued  a  final  rule  (“Final  Rule”) 
implementing HITECH’s statutory amendments to HIPAA.  The deadline for compliance 
is September 23, 2013. 
This training module focuses on two primary HIPAA rules,  
as amended by HITECH: 
Section 1:  The HIPAA Privacy Rule 
Section 2:  The HIPAA Security Rule 
Note:  There is also a Transaction Rule that is not covered in this course.  Healthcare providers need to 
be aware that under this Rule, treatment must be accurately billed using the prescribed code sets.  
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Section 1A 
HIPAA Privacy Rule 
Overview 
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Covered Entities 
Have a Duty to Protect PHI 
“covered entity” is any person or organization that 
furnishes, bills, or is paid for health care services in the 
normal  course  of  business.    Pursuant  to  HIPAA, 
individually identifiable health information collected or 
created by  a  covered  entity  is considered “protected 
health  information,” or  PHI University departments 
that  use  or  disclose  PHI  are  governed  by  HIPAA 
requirements. 
PHI defined  
Any information that can be used to identify a patient – whether living 
or  deceased  –  that  relates  to  the  patient’s  past,  present,  or  future 
physical  or  mental  health  or  condition,  including  healthcare  services 
provided and payment for those services. 
PHI is generally defined as:  
Employees may access PHI 
only when necessary to perform their job-related duties
Any of the following are considered 
identifiers under HIPAA.  
Patient names 
Geographic 
subdivisions     
(smaller than state)  
Telephone numbers 
Fax numbers 
Social Security 
numbers 
Vehicle identifiers 
E-mail addresses 
Web URLs and IP 
addresses 
Dates (except year) 
Names of relatives  
Full face photographs or 
images 
Healthcare record numbers 
Account numbers 
Biometric identifiers 
(fingerprints or voiceprints) 
Device identifiers 
Health plan beneficiary 
numbers 
Certificate/license numbers 
Any other unique number, 
code, or characteristic that 
can be linked to an individual. 
Affinity  Health  Plan,  Inc.  discovered  and  reported 
to  HHS that it  had  returned leased  photocopiers 
to the leasing agents without first erasing the data 
contained on the copier hard drives that included 
PHI.    The  breach  was  estimated  to  have  affected 
344,579  individuals.    Following  an  investigation, 
Affinity entered into a settlement agreement with 
HHS  providing  for  a  $1.2  million  payment  and  a 
corrective action plan. 
In general, HIPAA violations are enforced by the Department of Health 
and  Human  Services  (HHS).    However,  pursuant  to HITECH,  state 
attorneys general are also permitted to bring civil actions and recover 
monetary awards that may be shared with harmed individuals. 
reality 
Copiers:  erase all data from hard drives. 
Faxes: confirm authorization instructions; verify telephone numbers 
before faxing;  when possible, use pre-programmed numbers. 
Devices: encrypt; enable and use password protection. 
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