164.308(a)(3) Administrative Safeguards

Information Access Management

High Risk Complex Implementation High Cost

Implement policies and procedures for authorizing access to ePHI that are consistent with the applicable requirements of the Security Rule.

Implementation Guidance

Develop comprehensive information access management policies including:
• Access authorization procedures
• Access establishment and modification procedures
• Access review and recertification processes
• Emergency access procedures
• Access termination procedures
• Documentation of access decisions

Key requirements:
- Isolating healthcare clearinghouse functions
- Access authorization based on job functions
- Regular access reviews and updates
- Emergency access procedures
- Proper documentation of all access decisions

Required Documentation

• Information access management policies
• Access authorization procedures
• Access establishment and modification procedures
• Access review and recertification procedures
• Emergency access procedures
• Access termination procedures
• Documentation of access decisions
• Regular review and update procedures

Best Practices

• Implement role-based access control (RBAC)
• Regular access reviews and recertification
• Document all access decisions and rationale
• Implement emergency access procedures
• Use automated access management tools
• Regular training on access management
• Monitor and audit access regularly

Common Violations

• Inadequate access authorization procedures
• Failure to implement regular access reviews
• Lack of emergency access procedures
• Insufficient documentation of access decisions
• Failure to isolate healthcare clearinghouse functions
• Inadequate access termination procedures

Testing Procedures

• Review access management policies and procedures
• Test access authorization processes
• Verify access review and recertification procedures
• Test emergency access procedures
• Review access termination procedures
• Verify documentation of access decisions
• Test monitoring and auditing capabilities

Audit Considerations

• Access management policies and procedures
• Access authorization and review processes
• Emergency access procedures
• Access termination procedures
• Documentation of access decisions
• Monitoring and auditing capabilities
• Regular review and update procedures

NIST Cybersecurity Framework Alignment

This HIPAA control aligns with the following NIST Cybersecurity Framework functions and controls:

Identify (ID)

  • ID.AM-1: Physical devices and systems within the organization are inventoried
  • ID.AM-2: Software platforms and applications within the organization are inventoried
  • ID.AM-3: Organizational communication and data flows are mapped

Protect (PR)

  • PR.AC-1: Identities and credentials are issued, managed, verified, revoked, and audited
  • PR.AC-3: Remote access is managed
  • PR.DS-1: Data-at-rest is protected
  • PR.DS-2: Data-in-transit is protected

Detect (DE)

  • DE.AE-1: A baseline of network operations and expected data flows is established
  • DE.CM-1: The network is monitored to detect potential cybersecurity events
  • DE.CM-3: Personnel activity is monitored to detect potential cybersecurity events

Respond (RS)

  • RS.CO-1: Personnel know their roles and order of operations when a response is needed
  • RS.CO-2: Incidents are reported consistent with established criteria
  • RS.AN-1: Notifications from detection systems are investigated

Recover (RC)

  • RC.RP-1: Recovery plan is executed during or after a cybersecurity incident
  • RC.IM-1: Recovery plans incorporate lessons learned
  • RC.CO-1: Public relations are managed

Note: This mapping provides a general alignment between HIPAA controls and NIST Framework functions. Specific implementation may vary based on your organization's risk profile and compliance requirements.

Implementation Templates & Checklists

Download our expert-developed templates and checklists to implement this control effectively:

Implementation Checklist

Step-by-step checklist to ensure complete implementation of this control

Download Checklist

Policy Template

Ready-to-customize policy template for this specific control

Download Template

Risk Assessment Form

Comprehensive risk assessment form for this control

Download Form

Training Materials

Staff training materials and awareness resources

Download Materials

Expert Implementation Recommendations

Based on our experience with 500+ healthcare organizations, here are our expert recommendations for implementing this control:

High Priority

Start with Risk Assessment

Conduct a comprehensive risk assessment to identify specific vulnerabilities and threats related to this control. This will help prioritize implementation efforts and allocate resources effectively.

  • Identify all systems and data covered by this control
  • Assess current security measures and gaps
  • Evaluate potential impact of security incidents
  • Document findings and remediation priorities
Medium Priority

Develop Comprehensive Policies

Create detailed policies and procedures that address all aspects of this control. Ensure policies are specific, actionable, and aligned with your organization's risk profile.

  • Define roles and responsibilities clearly
  • Establish approval workflows and escalation procedures
  • Include specific technical requirements and standards
  • Regular review and update schedules
Low Priority

Implement Monitoring and Testing

Establish ongoing monitoring and testing procedures to ensure the control remains effective over time. Regular testing helps identify new vulnerabilities and compliance gaps.

  • Automated monitoring where possible
  • Regular manual testing and validation
  • Incident response procedures
  • Continuous improvement processes

Recommended Implementation Timeline

1

Week 1-2: Assessment & Planning

Conduct risk assessment and develop implementation plan

2

Week 3-4: Policy Development

Create and review policies and procedures

3

Week 5-8: Implementation

Deploy technical controls and train staff

4

Week 9-10: Testing & Validation

Test controls and validate compliance

Related Controls

164.308(a)(1) - Security Officer
164.308(a)(2) - Workforce Security
164.312(a)(1) - Access Control
164.312(a)(2) - Audit Controls

Quick Facts

Control ID: 164.308(a)(3)
Category: Administrative Safeguards
Subcategory: Security Management Process
Risk Level: High
Difficulty: Complex
Cost: High
Timeframe: 3-6 months
Views: 31
Last Updated: Nov 22, 2025

Actions

Get Expert Help Free Assessment

Additional Resources

• NIST SP 800-66 Rev. 2: Information Access Management Guidance
• HHS Information Access Management Guidance
• Role-Based Access Control Implementation Guide
• Access Management Best Practices
• Emergency Access Procedures Template

Related Controls

164.308(a)(7) High

Evaluation

Perform a periodic technical and non-technical evaluation, based initially upon the standards implemented under this rul...

164.308(a)(5) Critical

Security Incident Procedures

Implement policies and procedures to address security incidents....

164.308(a)(2) High

Workforce Security

Implement policies and procedures to ensure that all members of the workforce have appropriate access to electronic prot...