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Quick Review 
receive a copy of the University’s Notice of Privacy Practices 
receive a copy of their healthcare records in electronic form 
ask for corrections to their healthcare records    
receive an accounting of when and to whom their PHI has been shared 
restrict how their PHI is used and shared 
authorize confidential communications of their PHI to others 
receive notice of a breach of their unsecured PHI  
file a HIPAA complaint 
Under HIPAA, patients have the right to: 
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Quick Review 
The University may use or share only the minimum necessary information to 
perform its duties. 
Patients must sign an authorization form before the University can release their 
PHI to a third party not involved in providing healthcare.  
A researcher or healthcare provider is not entitled to use PHI in research 
without the appropriate HIPAA authorization or a waiver of authorization
The University must obtain an individual’s specific authorization before using his 
or her PHI for the sale of PHImarketing, and some fundraising efforts. 
A contractor providing services involving PHI is called a Business Associate. 
A covered entity and business associate must enter into a Business Associate 
Agreement (“BAA”). 
Business Associates are directly liable for HIPAA compliance and must ensure 
that their employees or subcontractors receive HIPAA training and employ 
appropriate safeguards for PHI.  
HIPAA protections apply to a deceased person’s PHI for 50 years after they 
have died. 
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Section 2 
HIPAA Security Rule 
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HIPAA Security Rule 
Confidentiality means that data or information is not made 
available or disclosed to unauthorized persons or processes. 
Integrity means that data or information has not been altered or 
destroyed in an unauthorized manner. 
Availability means that data or information is accessible and 
useable upon demand only by an authorized person. 
The HIPAA Security Rule concentrates on safeguarding PHI by 
focusing on the confidentiality, integrity, and availability of PHI. 
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Security Standards/Safeguards 
Safeguards must: 
Protect PHI from accidental or intentional 
unauthorized use/disclosure in computer systems 
(including social networking sites such as Facebook, 
Twitter and others) and work areas; 
Limit accidental disclosures (such as discussions 
in waiting rooms and hallways); and 
Include practices such as encryption, document 
shredding, locking doors and file storage areas, and 
use of passwords and codes for access. 
The University is required to have administrative, technical, and 
physical safeguards to protect the privacy of PHI. 
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Irritated by a patient who was always late to her pre-
natal appointments, a Missouri doctor posted to her 
personal Facebook page, “may I show up late to her 
delivery?” A reader took a screen shot of the doctor’s 
comment and posted it to the employing hospital’s 
Facebook page for expectant mothers where many 
wrote to demand the doctor’s termination.   
The doctor’s post revealed the patient’s 
induction date and that she had previously 
suffered a stillbirth making identification likely.  
The employing hospital publicly issued a 
comment decrying the incident.  
University employees should never disclose work-related sensitive 
information through social media such as Facebook, Twitter, and Google+. 
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Malicious Software 
Employees should utilize antivirus and anti-spyware software, and update it 
regularly  with  patches  (links  can  be  found  through  UNC  Shareware 
Distribution at https://shareware.unc.edu/links.html). 
Safe Internet browsing habits can also reduce the likelihood of an infection; do 
not open email or click on embedded links from an unknown or untrusted 
If the computer or mobile device you are using stores work-related sensitive 
information,  personal use of the web is not recommended. 
Viruses, worms, spyware, and spam are examples of  
malicious software, sometimes known as “malware”. 
Viruses “infect” your  computer by modifying how it operates and, in 
many cases, destroying data.  
Viruses spread to other machines by the actions of users, such as 
opening infected email attachments. 
Viruses can forward PHI to unauthorized persons by attaching 
themselves to documents, which are then emailed by the virus. 
Newer viruses have their own email engines, enabling them to send 
email without having to use an email client or server.  
Many viruses also install a “backdoor” on affected computer systems 
allowing for unauthorized access and collection of Sensitive 
Another major threat to the 
University’s information system and 
to your data is computer viruses. 
Worms are programs that can: 
run independently without user action; 
spread complete working versions of themselves onto other 
computers on a network within seconds; and 
quickly overwhelm computer resources with the potential for 
data destruction as well as unauthorized disclosure of sensitive 
Spyware is software that is secretly loaded onto your computer, 
monitors your activities, and shares that information 
without your knowledge.  
Malicious websites 
can install spyware on every computer 
that visits those sites. 
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