HIPAA Compliance Consultant
for Small Practices

HIPAA consulting helps you put the Privacy Rule, Security Rule, and Breach Notification Rule into practice. We adapt the process to fit your field. That means your workflows, your staff, and your risks.

HIPAA Definitions for Healthcare Organizations

Covered Entity means a health plan, healthcare clearinghouse, or healthcare provider that transmits health information electronically in connection with a HIPAA-covered transaction (45 CFR §160.103). This includes medical practices, dental offices, behavioral health providers, pharmacies, hospitals, and health insurance companies.

Business Associate is a person or entity that performs functions or activities involving protected health information (PHI) on behalf of a covered entity, or provides services to a covered entity involving PHI access (45 CFR §160.103). Examples include EHR vendors, IT service providers, billing companies, cloud hosting services, and shredding companies.

Protected Health Information (PHI) is individually identifiable health information created, received, maintained, or transmitted by a covered entity or business associate (45 CFR §160.103). PHI includes medical records, treatment plans, billing data, insurance information, and any health data that can identify a specific individual.

Core HIPAA Compliance Requirements

These six requirements apply to every covered entity and business associate. Each has specific obligations under the HIPAA regulations. We start with the highest-risk areas first.

1. Security Risk Assessment (SRA) - Required under 45 CFR §164.308(a)(1)(ii)(A). Organizations must identify threats and vulnerabilities to all electronic PHI (ePHI) they create, receive, maintain, or transmit. A HIPAA gap analysis typically follows the SRA to map findings to specific control deficiencies.
2. Written policies and procedures - Required under 45 CFR §164.316(a). Must address privacy, security, breach notification, and workforce conduct. Policies must reflect the organization's actual workflows. Generic templates that do not match practice operations consistently produce audit findings.
3. Workforce training - Required under 45 CFR §164.308(a)(5)(i). All workforce members with PHI access must receive HIPAA training at hire and when policies change. Training records must be retained for six years per §164.530(j).
4. Business Associate Agreements (BAAs) - Required under 45 CFR §164.502(e). Must be executed with all vendors and service providers that create, receive, maintain, or transmit PHI on behalf of the organization. BAA management includes maintaining a current vendor inventory, confirming BAA coverage for all PHI-touching relationships, and tracking renewal dates.
5. Documentation retention - HIPAA requires compliance documentation to be retained for a minimum of six years per 45 CFR §164.530(j). This includes risk assessments, policies, training records, BAAs, and breach documentation.
6. Breach notification within 60 days - Covered entities must notify affected individuals within 60 days of discovering a breach of unsecured PHI per 45 CFR §164.404(b). Breaches affecting 500 or more individuals require HHS and media notification per §164.406 and §164.408. Incident management procedures must be documented in advance to meet these timelines.

Why Specialty Alignment Matters in HIPAA Consulting

Different healthcare specialties face different HIPAA risks.

Medical practices manage complex EHR integrations and multi-provider access controls. A common risk is staff sharing login credentials across workstations, which violates the unique user identification requirement under 45 CFR §164.312(a)(2)(i).

Dental offices handle digital imaging data (X-rays, CBCT scans) that qualifies as ePHI. A frequent gap is unencrypted imaging files stored on local drives or transferred via USB without encryption.

Behavioral health providers must address 42 CFR Part 2 substance use disorder protections alongside HIPAA. The primary risk is inadvertent disclosure of psychotherapy notes or substance use records through misdirected communications.

Pharmacies manage high-volume prescription data with multiple system integrations. A typical finding is point-of-sale terminals that display patient information on screens visible to other customers.

Business associates must demonstrate compliance to covered entity partners through contract-grade documentation, which requires coordinated BAA management and vendor oversight.

The Office for Civil Rights (OCR) enforces HIPAA with civil monetary penalties ranging from $141 to $2,134,831 per violation category per calendar year under 45 CFR §160.404. Criminal penalties under 42 U.S.C. §1320d-6 can reach $250,000 and up to 10 years imprisonment.