Incident and Breach Reporting and Mitigation Sample Clauses
Incident and Breach Reporting and Mitigation
Documenting and Reporting Breaches 6.1 Business Associate shall report to Covered Entity any Breach of Unsecured PHI, including Breaches reported to it by a Subcontractor, as soon as it (or any of its employees or agents) becomes aware of any such Breach, and in no case later than two (2) business days after it (or any of its employees or agents) becomes aware of the Breach, except when a law enforcement official determines that a notification would impede a criminal investigation or cause damage to national security. 6.2 Business Associate shall provide Covered Entity with the names of the individuals whose Unsecured PHI has been, or is reasonably believed to have been, the subject of the Breach and any other available information that is required to be given to the affected individuals, as set forth in 45 CFR § 164.404(c), and, if requested by Covered Entity, information necessary for Covered Entity to investigate the impermissible use or disclosure. Business Associate shall continue to provide to Covered Entity information concerning the Breach as it becomes available to it. Business Associate shall require its Subcontractor(s) to agree to these same terms and conditions. 6.3 When Business Associate determines that an impermissible acquisition, use or disclosure of PHI by a member of its workforce is not a Breach, as that term is defined in 45 CFR § 164.402, and therefore does not necessitate notice to the impacted individual(s), it shall document its assessment of risk, conducted as set forth in 45 CFR § 402(2). When requested by Covered Entity, Business Associate shall make its risk assessments available to Covered Entity. It shall also provide Covered Entity with 1) the name of the person(s) making the assessment, 2) a brief summary of the facts, and 3) a brief statement of the reasons supporting the determination of low probability that the PHI had been compromised. When a breach is the responsibility of a member of its Subcontractor’s workforce, Business Associate shall either 1) conduct its own risk assessment and draft a summary of the event and assessment or 2) require its Subcontractor to conduct the assessment and draft a summary of the event. In either case, Business Associate shall make these assessments and reports available to Covered Entity. 6.4 Business Associate shall require, by contract, a Subcontractor to report to Business Associate and Covered Entity any Breach of which the Subcontractor becomes aware, no later than two (2) business days after becomes aware of the Breach.
BREACH DISCOVERY AND NOTIFICATION 17 1. Following the discovery of a Breach of Unsecured PHI, CONTRACTOR shall notify 18 COUNTY of such Breach, however both parties agree to a delay in the notification if so advised by a 19 law enforcement official pursuant to 45 CFR § 164.412. 20 a. A Breach shall be treated as discovered by CONTRACTOR as of the first day on which 21 such Breach is known to CONTRACTOR or, by exercising reasonable diligence, would have been 22 known to CONTRACTOR. 23 b. CONTRACTOR shall be deemed to have knowledge of a Breach, if the Breach is 24 known, or by exercising reasonable diligence would have known, to any person who is an employee, 25 officer, or other agent of CONTRACTOR, as determined by federal common law of agency. 26 2. CONTRACTOR shall provide the notification of the Breach immediately to the COUNTY 27 Privacy Officer. CONTRACTOR’s notification may be oral, but shall be followed by written 28 notification within twenty four (24) hours of the oral notification. 29 3. CONTRACTOR’s notification shall include, to the extent possible: 30 a. The identification of each Individual whose Unsecured PHI has been, or is reasonably 31 believed by CONTRACTOR to have been, accessed, acquired, used, or disclosed during the Breach; 32 b. Any other information that COUNTY is required to include in the notification to 33 Individual under 45 CFR §164.404 (c) at the time CONTRACTOR is required to notify COUNTY or 34 promptly thereafter as this information becomes available, even after the regulatory sixty (60) day 35 period set forth in 45 CFR § 164.410 (b) has elapsed, including: 36 1) A brief description of what happened, including the date of the Breach and the date 37 of the discovery of the Breach, if known; 1 2) A description of the types of Unsecured PHI that were involved in the Breach (such 2 as whether full name, social security number, date of birth, home address, account number, diagnosis, 3 disability code, or other types of information were involved); 4 3) Any steps Individuals should take to protect themselves from potential harm 5 resulting from the Breach; 6 4) A brief description of what CONTRACTOR is doing to investigate the Breach, to 7 mitigate harm to Individuals, and to protect against any future Breaches; and 8 5) Contact procedures for Individuals to ask questions or learn additional information, 9 which shall include a toll-free telephone number, an e-mail address, Web site, or postal address. 10 4. COUNTY may require CONTRACTOR to provide notice to the Individual as required in 11 45 CFR § 164.404, if it is reasonable to do so under the circumstances, at the sole discretion of the 12 COUNTY. 13 5. In the event that CONTRACTOR is responsible for a Breach of Unsecured PHI in violation 14 of the HIPAA Privacy Rule, CONTRACTOR shall have the burden of demonstrating that 15 CONTRACTOR made all notifications to COUNTY consistent with this Subparagraph F and as 16 required by the Breach notification regulations, or, in the alternative, that the acquisition, access, use, or 17 disclosure of PHI did not constitute a Breach. 18 6. CONTRACTOR shall maintain documentation of all required notifications of a Breach or 19 its risk assessment under 45 CFR § 164.402 to demonstrate that a Breach did not occur. 20 7. CONTRACTOR shall provide to COUNTY all specific and pertinent information about the 21 Breach, including the information listed in Section E.3.b.(1)-(5) above, if not yet provided, to permit 22 COUNTY to meet its notification obligations under Subpart D of 45 CFR Part 164 as soon as 23 practicable, but in no event later than fifteen (15) calendar days after CONTRACTOR’s initial report of 24 the Breach to COUNTY pursuant to Subparagraph F.2. above. 25 8. CONTRACTOR shall continue to provide all additional pertinent information about the
Safeguards Monitoring and Reporting The Borrower shall do the following or cause the Project Executing Agency to do the following:
Handling Sensitive Personal Information and Breach Notification A. As part of its contract with HHSC Contractor may receive or create sensitive personal information, as section 521.002 of the Business and Commerce Code defines that phrase. Contractor must use appropriate safeguards to protect this sensitive personal information. These safeguards must include maintaining the sensitive personal information in a form that is unusable, unreadable, or indecipherable to unauthorized persons. Contractor may consult the “Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals” issued by the U.S. Department of Health and Human Services to determine ways to meet this standard. B. Contractor must notify HHSC of any confirmed or suspected unauthorized acquisition, access, use or disclosure of sensitive personal information related to this Contract, including any breach of system security, as section 521.053 of the Business and Commerce Code defines that phrase. Contractor must submit a written report to HHSC as soon as possible but no later than 10 business days after discovering the unauthorized acquisition, access, use or disclosure. The written report must identify everyone whose sensitive personal information has been or is reasonably believed to have been compromised. C. Contractor must either disclose the unauthorized acquisition, access, use or disclosure to everyone whose sensitive personal information has been or is reasonably believed to have been compromised or pay the expenses associated with HHSC doing the disclosure if: 1. Contractor experiences a breach of system security involving information owned by HHSC for which disclosure or notification is required under section 521.053 of the Business and Commerce Code; or 2. Contractor experiences a breach of unsecured protected health information, as 45 C.F.R. §164.402 defines that phrase, and HHSC becomes responsible for doing the notification required by 45 C.F.R. §164.404. HHSC may, at its discretion, waive Contractor's payment of expenses associated with HHSC doing the disclosure.
Reporting and Monitoring Please provide a brief description of the mechanisms proposed for this project for reporting to the UNDP and partners, including a reporting schedule.