ECU HIPAA Training

Version 1 (Current Version)
All Versions:
  • Version 1
TitleECU HIPAA Training
CategoryHealth Affairs
Sub-categoryHealth Affairs Matters - General

Effective: September 19, 2013

Revised: January 8, 2004; April 6, 2006; December 6, 2007; October 12, 2010; September 18, 2013

Transitioned from Interim to Permanent: July 17, 2014.


ECU HIPAA Privacy Office, 252-744-5200

Related Policies
Additional References

45 CFR 164 Subpart E: Privacy of Individually Identifiable Health Information

"Modification to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules; Final Rule," 78 Federal Register 17 (25 January 2013), pp. 5566-5702.

ECU Healthcare Components

1. Purpose

1.1. East Carolina University's Health Care Components ("ECU Health Care Components") must provide training to all members of its Workforce with respect to protected health information (PHI) that meets the requirements of HIPAA. The purpose of this regulation is to define a process to provide HIPAA training.

2. Definitions

2.1. Workforce means employees, volunteers, trainees, learners, faculty, students and any other person whose conduct, in the performance of work for an ECU Health Care Component, is under the direct control of such ECU Health Care Component, whether or not they are paid by the ECU Health Care Component.

3. Regulation

3.1. ECU Health Care Components must train all members of its Workforce on the policies and procedures with respect to PHI as necessary and appropriate for the members of the Workforce to carry out their functions within the ECU Health Care Component.

3.1.1. ECU Health Care Components must train: Each new member of its Workforce within a reasonable period of time after the person joins the Component's Workforce; and Each member of its Workforce whose functions are affected by a material change in the policies or procedures required by HIPAA within a reasonable period of time after the material change becomes effective.

3.2. An introduction to HIPAA Training may occur through various methods and may be facilitated by supervisors, managers, or trainers from different departments and/or sections from within any of ECU's Health Care Components.

3.3. All attendee documentation and training information will be maintained for a minimum of six years from the date of training.

4. Procedure

4.1. Initial Training:

4.1.1. All new Workforce members of ECU's Health Care Components must receive an introduction to HIPAA training during orientation.

4.1.2. New Workforce members must also complete an online HIPAA training that is offered through the ECU HIPAA Privacy Office within 30 days.

4.2. Visitors:

4.2.1. Visitors, volunteers, non ECU Students, etc. functioning or completing a clinical rotation, internship, or shadowing program in an ECU Health Care Component must complete HIPAA training through ECU or if applicable, through documented training at their host institution. Please contact the ECU HIPAA Privacy Office or visit the ECU HIPAA Privacy Training website for additional information on how to receive training.

4.3. Annual/Update Training:

4.3.1. All Workforce members will be required to receive updated HIPAA training annually.