Major Edmund Randolph, an active member of the United States Air Force, recently discovered through a public notice that his PII is being maintained by the federal government in a system of records. Because Major Randolph is very diligent about safeguarding his personal information and is aware of how this information could be vulnerable, he is interested in obtaining a copy and reviewing them for accuracy. Is Major Randolph able to obtain a copy of his records from the system of records and request changes to ensure that they are accurate?
A. No, even though the records at issue pertain to Major Randolph he is not entitled to a copy or request amendments.
B. Yes, pursuant to the Privacy Act, Major Randolph may obtain a copy of his records through the submission of a written request, but he is not able to request any changes to his records.
C. Yes, as an upstanding member of the United States Air Force, Major Randolph can
gain access and request changes to any PII maintained by the federal government.
D. Yes, Major Randolph is able to request to inspect and copy his records and can request an amendment to correct inaccurate information.
HIPAA Violations
1. Fines and civil penalties can be filed against any individual that negligently discloses or knowingly & willfully obtains, discloses or uses medical information
2. Fines can be brought against an institution for failing to prevent/report unauthorized access, use or disclosure of medical information
HIPAA Consequences
Civil Penalties: Range from $100 per violation to annual maximum of $1.5 million for repeated violations. Amount of penalty is
based on reasonable cause for HIPAA violation, willful neglect and corrective steps taken
Criminal Penalties: Consists of a fine up to $250,000 as well as a prison sentence of up to 10 years
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Terms in this set (40)
Under HIPAA, a covered entity (CE) is defined as:
All of the above
Under HIPAA, a CE is a health plan, a health care clearinghouse, or a health care provider engaged in standard electronic transactions covered by HIPAA.
The minimum necessary standard:
All of the above
The minimum necessary standard limits uses, disclosures, and requests for PHI to the minimum necessary amount of PHI needed to carry out the intended purposes of the use or disclosure. The minimum necessary standard does not apply to disclosures to, or requests by, a health care provider for treatment purposes. It also does not apply to uses or disclosures made to the individual or pursuant to the individual's authorization.
Which of the following would be considered PHI?
An individual's first and last name and the medical diagnosis in a physician's progress report
The HIPAA Privacy Rule applies to which of the following?
All of the above
The HIPAA Privacy Rule applies to PHI that is transmitted or maintained by a covered entity or a business associate in any form or medium.
Which of the following statements about the HIPAA Security Rule are true?
All of the above
The HIPAA Security Rule: Established a national set of standards for the protection of PHI that is created, received, maintained, or transmitted in electronic media by a HIPAA CE or BA; protects ePHI; and addresses three types of safeguards - administrative, technical and physical - that must be in place to secure individuals' ePHI.
The HIPAA Security Rule applies to which of the following:
PHI transmitted electronically
Which of the following are fundamental objectives of information security?
All of the above
Confidentiality, Integrity, and Availability are the fundamental objectives of health information security and the HIPAA Security Rule requires covered entities and business associates to protect against threats and hazards to these objectives.
Technical safeguards are:
Information technology and the associated policies and procedures that are used to protect and control access to ePHI
If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with the:
All of the above
If an individual believes that a DoD CE is not complying with HIPAA he or she may file a complaint with the DHA Privacy Office, HHS Secretary, and/or the MTF HIPAA Privacy Officer.
Which of the following are categories for punishing violations of federal health care laws?
All of the above
The three main categories of punishment for violating federal health care laws include: criminal penalties, civil money penalties, and sanctions.
Which HHS Office is charged with protecting an individual patient's health information privacy and security through the enforcement of HIPAA?
Office for Civil Rights (OCR)
A covered entity (CE) must have an established complaint process.
True
Which of the following are examples of personally identifiable information (PII)?
All of the above
PII means information that can be linked to a specific individual and may include the following: Social Security Number; DoD identification number; home address; home telephone; date of birth (year included); personal medical information; or personal/private information (e.g., an individual's financial data).
The e-Government Act promotes the use of electronic government services by the public and improves the use of information technology in the government.
True
A Systems of Records Notice (SORN) serves as a notice to the public about a system of records and must:
All of the above
A SORN serves as a notice to the public about a system of records and must: Specify routine uses (how the information will be used), be republished if a new routine use is created, and be provided to OMB and Congress and published in the Federal Register before the system is operational.
Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.
True
A breach as defined by the DoD is broader than a HIPAA breach (or breach defined by HHS).
True
Which of the following are common causes of breaches?
All of the above
Breaches are commonly associated with human error at the hands of a workforce member. Improper disposal of electronic media devices containing PHI or PII is also a common cause of breaches. Theft and intentional unauthorized access to PHI and PII are also among the most common causes of privacy and security breaches. Another common cause of a breach includes lost or stolen electronic media devices containing PHI and PII such as laptop computers, smartphones and USB storage drives. Lost or stolen paper records containing PHI or PII also are a common cause of breaches.
Which of the following are breach prevention best practices?
All of the above
You can help prevent a breach by accessing only the minimum amount of PHI/PII necessary and by promptly retrieving documents containing PHI/PII from the printer. You should always logoff or lock your workstation when it is unattended for any length of time.
When must a breach be reported to the U.S. Computer Emergency Readiness Team?
Within 1 hour of discovery
Which of the following are common causes of breaches?
-Theft and intentional unauthorized access to PHI and personally identifiable information (PII)
-Human error (e.g. misdirected communication containing PHI or PII)
-Lost or stolen electronic media devices or paper records containing PHI or PII
-All of the above
(correct)
A Privacy Impact Assessment (PIA) is an analysis of how information is handled:
-To ensure handling conforms to applicable legal, regulatory, and policy requirements regarding privacy
- To determine the risks and effects of collecting, maintaining and disseminating information in identifiable form in an electronic information system
-To examine and evaluate protections and alternative processes for handling
information to mitigate potential privacy risks
-All of the above (correct)
Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.
True (correct)
False
Under HIPAA, a covered entity (CE) is defined as:
A health plan
A health care clearinghouse
A
health care provider engaged in standard electronic transactions covered by HIPAA
All of the above (correct)
The e-Government Act promotes the use of electronic government services by the public and improves the use of information technology in the government.
True (correct)
False
What of the following are categories for punishing violations of federal health care laws?
Criminal penalties
Civil money penalties
Sanctions
All of the above (correct)
Technical safeguards are:
-Administrative actions, and policies and procedures that are used to manage the selection, development, implementation and maintenance of security measures to protect electronic PHI (ePHI). These safeguards also outline how to manage the
conduct of the workforce in relation to the protection of ePHI
- Physical measures, including policies and procedures that are used to protect electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion
- Information technology and the associated policies and procedures that are used to protect and control access to ePHI (correct)
-None of the above
An incidental use or disclosure is not a violation of the HIPAA Privacy Rule if the covered entity (CE) has:
-Implemented the minimum necessary standard
-Established appropriate administrative safeguards
-Established appropriate physical and technical safeguards
-All of the above (correct)
A covered entity (CE) must have an established complaint process.
False
True
(correct)
The HIPAA Security Rule applies to which of the following:
-PHI transmitted orally
-PHI on paper
- PHI transmitted electronically (correct)
-All of the above
Which of the following are breach prevention best practices?
-Access only the minimum amount of PHI/personally identifiable information (PII)
necessary
-Logoff or lock your workstation when it is unattended
- Promptly retrieve documents containing PHI/PHI from the printer
-All of this above (correct)
Which of the following are examples of personally identifiable information (PII)?
-Social Security number
- Home address
-Telephone
- All of the above (correct)
HIPAA provides individuals with the right to request an accounting of disclosures of their PHI.
-False
-True (correct)
If an individual believes that a DoD covered entity (CE) is not complying with HIPAA, he or she may file a complaint with the:
-DHA Privacy Office
-HHS Secretary
-MTF HIPAA Privacy Officer
- All of the above (correct)
The minimum necessary standard:
-Limits uses, disclosures, and requests for PHI to the minimum necessary amount of PHI needed to carry out the intended purposes of the use or disclosure
-Does not apply to exchanges between providers treating a patient
- Does not apply to uses or disclosures made to the individual or pursuant to the individual's authorization
- All of the above (correct)
When must a breach be reported to the U.S. Computer Emergency Readiness Team?
-Within 1 hour of discovery (correct)
- Within 24 hours of discovery
-Within 48 hours of discovery
-Within 72 hours of discovery
Administrative safeguards are:
- Administrative actions, and policies and procedures that are used to manage the selection, development, implementation and maintenance of security
measures to protect electronic PHI (ePHI). These safeguards also outline how to manage the conduct of the workforce in relation to the protection of ePHI (correct)
- Physical measures, including policies and procedures that are used to protect electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion
- Information technology and the associated policies and procedures that are used to protect and control access to
ePHI
- None of the above
A breach as defined by the DoD is broader than a HIPAA breach (or breach defined by HHS).
True (correct)
False
Which HHS Office is charged with protecting an individual patient's health information privacy and security through the enforcement of HIPAA?
- Office of Medicare Hearings and Appeals
(OMHA)
- Office for Civil Rights (OCR) (correct)
- Office of the National Coordinator for Health Information Technology (ONC)
- None of the above
Physical safeguards are:
- Administrative actions, and policies and procedures that are used to manage the selection, development, implementation and maintenance of security measures to protect electronic PHI (ePHI). These safeguards also outline how to manage
the conduct of the workforce in relation to the protection of ePHI
- Physical measures, including policies and procedures that are used to protect electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion (correct)
- Information technology and the associated policies and procedures that are used to protect and control access to ePHI
- None of the above
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