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2. © Clearwater Compliance LLC | All Rights Reserved Legal Disclaimer Legal Disclaimer. This information does not constitute legal advice and is for educational purposes only. This information is based on current federal law and subject to change based on changes in federal law or subsequent interpretative guidance. Since this information is based on federal law, it must be modified to reflect state law where that state law is more stringent than the federal law or other state law exceptions apply. This information is intended to be a general information resource regarding the matters covered, and may not be tailored to your specific circumstance. YOU SHOULD EVALUATE ALL INFORMATION, OPINIONS AND ADVICE PROVIDED HEREIN IN CONSULTATION WITH YOUR LEGAL OR OTHER ADVISOR, AS APPROPRIATE. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by Clearwater Compliance LLC.

3. © Clearwater Compliance LLC | All Rights Reserved Clearwater HIPAA Privacy and Breach Notification Assessment™ Guided Tour (800)704-3394 sales@clearwatercompliance.com

4. © Clearwater Compliance LLC | All Rights Reserved Passion: Implementing Privacy and Security by design; aiding others in achieving and maintaining compliance Jon Stone, MPA, PMP 25+ years in Healthcare in the provider, payer and healthcare quality improvement fields Innovator | Strategic Program Manager | Consultant | Executive 15+ years of strategic leadership for compliance and Healthcare information technology projects involving the most sensitive ePHI for companies such as CIGNA, Healthways and Ingenix. PMP, MPA - Healthcare Policy and Administration Jon Stone, MPA, PMP 615-210-9612 Jon.Stone@ClearwaterCompliance.com

5. © Clearwater Compliance LLC | All Rights Reserved Wes Morris, CHPS 25+ years in Healthcare 20 years in Clinical Care 10+ years specific experience in HIPAA Privacy and Security Experienced Hospital Privacy and Security Officer, Team Lead and Subject Matter Expert Certified in Healthcare Privacy and Security (CHPS) Examination Development Committee Member for CHPS Exam Mentor HIM students and candidates Wes Morris, CHPS Wes.morris@clearwatercompliance.com

6. © Clearwater Compliance LLC | All Rights Reserved Lee Painter, CISSP, C|EH 15+ years in Information Assurance and Computer Network Defense 15+ years training customers on the need to understand and adopt best practices Experience as an Information Systems Security Officer for the Department of Homeland Security Passionate Security Professional with a drive to provide not just knowledge but understanding Certified Information Systems Security Professional(CISSP) Certified Ethical Hacker(C|EH) Lee Painter, CISSP, C│EH lee.painter@clearwatercompliance.com

7. © Clearwater Compliance LLC | All Rights ReservedObjective Learn how to use the Clearwater HIPAA Privacy Breach Notification Assessment™ Software as a Service Agenda Regulatory Background Features Software walkthrough Product Benefits

8. © Clearwater Compliance LLC | All Rights Reserved FrameFrame MonitorMonitor RespondRespondAssessAssess HIPAA Business Risk Management Life Cycle Privacy Assessment Security Assessment Risk Analysis ePHI Discovery Risk Response Remediation Risk Strategy Governance Auditing Technical Testing Workforce Training Workforce Training

9. © Clearwater Compliance LLC | All Rights Reserved Three Pillars of HIPAA-HITECH Compliance… Privacy Security BreachNotification …… HITECH HIPAA Breach Notification IFR 6 pages / 2K words 4 Standards 9 Implementation Specs Privacy Final Rule 75 pages / 27K words 56 Standards ~ 54 “dense” Implementation Specs Security Final Rule 18 pages / 4.5K words 22 Standards ~50 Implementation Specs OMNIBUS FINAL RULE

10. © Clearwater Compliance LLC | All Rights Reserved What’s New?

11. © Clearwater Compliance LLC | All Rights Reserved What’s New? The # of Data Breaches are Up The Average Cost of a Data Breach is Up The # of Complaints to HHS is Up The # of Investigations by OCR is Up State Privacy Laws are tightening

12. © Clearwater Compliance LLC | All Rights Reserved What’s New? State AGs are flexing their muscles The Courts are beginning to “widen their view” of data breach damages “Meaningful Use” Audits are underway False Claim Act Violations SEC requiring Disclosure

13. © Clearwater Compliance LLC | All Rights Reserved The Intersection of Privacy & Security Choice Notice Access Controls Safeguards Confidentiality Integrity Availability

14. © Clearwater Compliance LLC | All Rights Reserved Why Do A Privacy Assessment? OCR Preliminary Observations: Weaknesses in Meeting Privacy Rule Requirements OCR Corrective Action Plans: Strengthen Privacy Administrative Requirements “Wall of Shame” and Industry Surveys: More Breaches Result from Insider Actions than Outsider Hackers Complaints to OCR: Highlight Privacy Concerns and Violations

15. © Clearwater Compliance LLC | All Rights Reserved Clearwater HIPAA Privacy & Breach Notification Assessment™

16. © Clearwater Compliance LLC | All Rights Reserved Three Key Compliance Questions 1.Is it documented? Policies, Procedures and Documentation 3.Is it Reasonable and Appropriate? Comply with the implementation specification 2.Are you doing it? Using, Applying, Practicing and Enforcing

17. © Clearwater Compliance LLC | All Rights Reserved Features

19. Benefits of a Privacy Assessment 1.Prepare for Mandatory Audits or Investigations 2.Build Solid Educational Foundation 3.Re-energize Overall Compliance Program 4.Establish a Baseline for Progress Monitoring 5.Understand Gaps in Compliance 6.Develop/Execute on a Thoughtful Remediation Plan 7.Receive an Independent, Objective 3 rd Party Review 8.Reduce the Risk of a Costly Data Breach

20. © Clearwater Compliance LLC | All Rights Reserved Support  Unlimited support during normal business hours  Phone and email support Training  60-90 minutes of live web based training  Extensive free self-service training User Provisioning  Easy self service capabilities to add unlimited numbers of users  Add additional business entities and perform multiple concurrent assessments for an additional reasonable price

21. © Clearwater Compliance LLC | All Rights Reserved Ease of Access  Available 7x24 from an internet connection  No software download required  Supports all common browsers Business Continuity  Customer data is backed up every 15 minutes  Returned to operations in under two hours Protection  Strong firewalls  All data sent or received uses TLS 1.1 encryption  Passwords are stored using strong encryption

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