164.308(a)(3) Administrative Safeguards

Information Access Management

High Risk Complex High

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

Implementation Resources

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

Quick Facts

Control ID 164.308(a)(3)
Category Administrative Safeguards
Risk Level High
Difficulty Complex
Est. Cost High
Timeframe 3-6 months
Last Updated Mar 1, 2026

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