Definition of Breach
A breach is, generally, an impermissible use or disclosure under the
Privacy Rule that compromises the security or privacy of the protected
health information. An impermissible use or disclosure of protected
health information is presumed to be a breach unless the covered entity
or business associate, as applicable, demonstrates that there is a low
probability that the protected health information has been compromised
based on a risk assessment of at least the following factors:
- The nature and extent of the protected health information
involved, including the types of identifiers and the likelihood of
re-identification;
- The unauthorized person who used the protected health information or to whom the disclosure was made;
- Whether the protected health information was actually acquired or viewed; and
- The extent to which the risk to the protected health information has been mitigated.
Covered entities and business associates, where applicable, have
discretion to provide the required breach notifications following an
impermissible use or disclosure without performing a risk assessment to
determine the probability that the protected health information has been
compromised.
There are three exceptions to the definition of “breach.” The first
exception applies to the unintentional acquisition, access, or use of
protected health information by a workforce member or person acting
under the authority of a covered entity or business associate, if such
acquisition, access, or use was made in good faith and within the scope
of authority. The second exception applies to the inadvertent disclosure
of protected health information by a person authorized to access
protected health information at a covered entity or business associate
to another person authorized to access protected health information at
the covered entity or business associate, or organized health care
arrangement in which the covered entity participates. In both cases, the
information cannot be further used or disclosed in a manner not
permitted by the Privacy Rule. The final exception applies if the
covered entity or business associate has a good faith belief that the
unauthorized person to whom the impermissible disclosure was made, would
not have been able to retain the information.
| In today's digital landscape, data breaches are an unfortunate reality that businesses of all sizes must contend with. A single security lapse can lead to significant financial losses, reputational damage, and legal headaches. While prevention is paramount, having a clear and well-defined data breach reporting procedure is crucial for minimizing the fallout when the inevitable happens. This article will guide you through the essential steps your business needs to take. Why a Solid Breach Reporting Procedure is Non-Negotiable Data breaches are not just a concern for large corporations; they affect small and medium-sized businesses (SMBs) just as much, if not more so. A robust reporting procedure serves multiple critical purposes: Compliance with Regulations: Various data privacy regulations, like GDPR, CCPA, and others, mandate specific reporting timelines and requirements. Failure to comply can result in hefty fines and legal action.Minimizing Damage: Swift and decisive action can significantly limit the scope ...read more |
| When your business experiences a data breach, notify law enforcement, other affected businesses, and affected individuals. Determine your legal requirements. All states, the District of Columbia, Puerto Rico, and the Virgin Islands have enacted legislation requiring notification of security breaches involving personal information. In addition, depending on the types of information involved in the breach, there may be other laws or regulations that apply to your situation. Check state and federal laws or regulations for any specific requirements for your business. Notify law enforcement. Call your local police department immediately. Report your situation and the potential risk for identity theft. The sooner law enforcement learns about the theft, the more effective they can be. If your local police aren’t familiar with investigating information compromises, contact the local office of the FBI or the U.S. Secret Service. For incidents involving mail theft, contact the U.S. Postal Inspection Service. Did the ...read more |
| Think about service providers. If service providers were involved, examine what personal information they can access and decide if you need to change their access privileges. Also, ensure your service providers are taking the necessary steps to make sure another breach does not occur. If your service providers say they have remedied vulnerabilities, verify that they really fixed things. Check your network segmentation. When you set up your network, you likely segmented it so that a breach on one server or in one site could not lead to a breach on another server or site. Work with your forensics experts to analyze whether your segmentation plan was effective in containing the breach. If you need to make any changes, do so now. Work with your forensics experts. Find out if measures such as encryption were enabled when the breach happened. Analyze backup or preserved data. Review logs to determine ...read more |
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Blog Home
Newest Blog Entries
1/21/25 Healthcare Data Breaches and Their Devastating Impact
1/21/25 Your Essential Guide to Data Breach Reporting Procedures
1/21/25 Understanding Your Obligations in Data Breach Reporting
11/16/22 Administrative Requirements and Burden of Proof
11/16/22 Notification by a Business Associat
11/16/22 Breach Notification Requirements
11/16/22 Unsecured Protected Health Information and Guidance
11/16/22 Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals
11/16/22 Definition of Breach
11/16/22 Breach Notification Rule
11/16/22 Notify Individuals
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