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, a health care clearinghouse, or a health care provider that sends health data online as part of a HIPAA-covered transaction (45 CFR §160.103). That takes in medical practices, dental offices, behavioral health providers, pharmacies, hospitals, and insurers.

Business Associate is a person or firm that does work with protected health information (PHI) for a covered entity, or gives it a service that puts them in reach of PHI (45 CFR §160.103). Think EHR vendors, IT services, billing firms, cloud hosts, 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 takes in medical records, care plans, billing data, insurance data, and any health data that can identify one person.

Core HIPAA Compliance Requirements

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

1. Security Risk Assessment (SRA) - Called for under 45 CFR §164.308(a)(1)(ii)(A). You have to name the threats and weak spots around every bit of electronic PHI (ePHI) you create, receive, maintain, or transmit. A HIPAA gap analysis often comes next, to tie each finding to the control behind it.
2. Written policies and procedures - Called for under 45 CFR §164.316(a). They have to cover privacy, security, breach notice, and how staff behave. And they have to match how you really work. A stock template that does not fit the office turns up as an audit finding again and again.
3. Workforce training - Called for under 45 CFR §164.308(a)(5)(i). Every workforce member who can reach PHI is trained at hire, and again when a policy changes. Keep the records for six years per §164.530(j).
4. Business Associate Agreements (BAAs) - Called for under 45 CFR §164.502(e). Get one signed with every vendor that creates, receives, maintains, or transmits PHI for you. BAA management means keeping the vendor list current, checking that each one who touches PHI is covered, and watching renewal dates.
5. Documentation retention - HIPAA says you keep your records at least six years per 45 CFR §164.530(j). That covers risk assessments, policies, training logs, BAAs, and breach files.
6. Breach notification within 60 days - A covered entity tells the people affected within 60 days of finding a breach of unsecured PHI, per 45 CFR §164.404(b). If it hits 500 or more, HHS and the press get told too, per §164.406 and §164.408. Your Incident management steps have to be written down ahead of time to hit those dates.

Why Specialty Alignment Matters in HIPAA Consulting

Different healthcare specialties face different HIPAA risks.

Medical practices juggle EHR links and access for many providers at once. A common risk: staff sharing one log-in across workstations, which runs against the unique user ID rule at 45 CFR §164.312(a)(2)(i).

Dental offices hold digital images (X-rays, CBCT scans) that count as ePHI. A common gap: those files sit on a local drive, or move on a USB stick, with no encryption.

Behavioral health providers have to meet 42 CFR Part 2 for substance use records on top of HIPAA. The main risk: a psychotherapy note or a substance use record goes out to the wrong person.

Pharmacies move a lot of prescription data across many linked systems. A typical finding: the screen at the counter shows patient data the next customer can read.

A business associate has to prove itself to the covered entities it serves, with records that hold up in a contract review. That takes BAA management and vendor oversight working together.

The Office for Civil Rights (OCR) enforces HIPAA. Civil money penalties run from $145 to $2,190,294 per violation category, per year, under 45 CFR §160.404. Criminal penalties under 42 U.S.C. §1320d-6 can reach $250,000 and up to 10 years in prison.