Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals

Protected health information (PHI) is rendered unusable, unreadable, or indecipherable to unauthorized individuals if one or more of the following applies:

  1. Electronic PHI has been encrypted as specified in the HIPAA Security Rule by “the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without use of a confidential process or key” (45 CFR 164.304 definition of encryption) and such confidential process or key that might enable decryption has not been breached.  To avoid a breach of the confidential process or key, these decryption tools should be stored on a device or at a location separate from the data they are used to encrypt or decrypt.  The encryption processes identified below have been tested by the National Institute of Standards and Technology (NIST) and judged to meet this standard.
    • Valid encryption processes for data at rest are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.1
    • Valid encryption processes for data in motion are those which comply, as appropriate, with NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPsec VPNs; or 800-113, Guide to SSL VPNs, or others which are Federal Information Processing Standards (FIPS) 140-2 validated.
  2. The media on which the PHI is stored or recorded has been destroyed in one of the following ways:
    • Paper, film, or other hard copy media have been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed. Redaction is specifically excluded as a means of data destruction.
    • Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media Sanitization such that the PHI cannot be retrieved.


In today's interconnected world, data breaches are an unfortunate reality. Whether it's a sophisticated cyberattack or a simple human error, the unauthorized access to sensitive information can have devastating consequences for individuals and organizations alike. While prevention is paramount, knowing how to respond effectively in the aftermath of a breach is equally critical. A key aspect of that response is data breach reporting. Why is Data Breach Reporting So Important? Data breach reporting is the process of notifying relevant authorities and affected parties about a security incident that has compromised personal or sensitive data. It's more than just an administrative formality; it's a legal obligation in many jurisdictions and has a profound impact on: Protecting Individuals: Prompt reporting allows affected individuals to take necessary steps to mitigate potential harm, such as changing passwords, monitoring their credit reports, and being vigilant against identity theft.Legal Compliance: Numerous laws and regulations, like ...read more



If a breach of unsecured protected health information occurs at or by a business associate, the business associate must notify the covered entity following the discovery of the breach.  A business associate must provide notice to the covered entity without unreasonable delay and no later than 60 days from the discovery of the breach.  To the extent possible, the business associate should provide the covered entity with the identification of each individual affected by the breach as well as any other available information required to be provided by the covered entity in its notification to affected individuals. ...read more



Following a breach of unsecured protected health information, covered entities must provide notification of the breach to affected individuals, the Secretary, and, in certain circumstances, to the media. In addition, business associates must notify covered entities if a breach occurs at or by the business associate. Individual Notice Covered entities must notify affected individuals following the discovery of a breach of unsecured protected health information. Covered entities must provide this individual notice in written form by first-class mail, or alternatively, by e-mail if the affected individual has agreed to receive such notices electronically. If the covered entity has insufficient or out-of-date contact information for 10 or more individuals, the covered entity must provide substitute individual notice by either posting the notice on the home page of its web site for at least 90 days or by providing the notice in major print or broadcast media where the affected individuals ...read more



Notify individuals. If you quickly notify people that their personal information has been compromised, they can take steps to reduce the chance that their information will be misused. In deciding who to notify, and how, consider: state lawsthe nature of the compromisethe type of information takenthe likelihood of misusethe potential damage if the information is misused For example, thieves who have stolen names and Social Security numbers can use that information not only to sign up for new accounts in the victim’s name, but also to commit tax identity theft. People who are notified early can take steps to limit the damage. When notifying individuals, the FTC recommends you: Consult with your law enforcement contact about the timing of the notification so it doesn’t impede the investigation.Designate a point person within your organization for releasing information. Give the contact person the latest information about the breach, your response, and how ...read more

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