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HIPAA · Security Rule · 45 CFR Part 164

The HIPAA
Security Rule

The HIPAA Security Rule requires every covered entity and business associate to protect electronic Protected Health Information (ePHI) through three families of safeguards — administrative, physical, and technical — that together preserve its confidentiality, integrity, and availability.

Safeguards span administrative, physical, and technical controls, each with Required and Addressable implementation specifications.

3Safeguard categories
18Standards
500+Audits delivered

45 CFR Part 164 Subpart C · U.S. Dept. of Health & Human Services (OCR) · Last reviewed June 2026

Direct Answer

What does the HIPAA Security Rule require?

The HIPAA Security Rule requires every covered entity and business associate to protect electronic PHI (ePHI) through three families of safeguards — administrative, physical, and technical — that together preserve the confidentiality, integrity, and availability of that data. It is enforced by the HHS Office for Civil Rights (hhs.gov/hipaa), and a documented risk analysis is the mandatory starting point. Like all of HIPAA, the Security Rule is a compliance obligation rather than a certification — there is no official “HIPAA certificate”; you demonstrate conformance through implemented safeguards and evidence.

The Three Safeguard Families

Administrative, Physical & Technical

The Security Rule organises ePHI protection into three families of safeguards. Each contains standards with Required or Addressable implementation specifications.

Administrative

Policies, procedures, and workforce training

Physical

Facility access and workstation controls

Technical

Access controls, audit logs, encryption

Required vs Addressable

Security Rule specifications are either Required (must implement) or Addressable (assess and implement if reasonable, or document why an equivalent measure is used).

Safeguard familyFocusRepresentative standards
AdministrativePolicies, procedures, and workforce management of securitySecurity Management Process (incl. risk analysis), assigned security responsibility, workforce security, training, contingency plan
PhysicalProtecting facilities, equipment, and media that hold ePHIFacility access controls, workstation use and security, device and media controls (disposal, re-use)
TechnicalTechnology that controls access to and protects ePHIAccess control (unique IDs, auto-logoff, encryption), audit controls, integrity controls, authentication, transmission security

45 CFR § 164.308

Administrative Safeguards

Administrative actions, policies, and procedures to manage the selection, development, and maintenance of security measures.

Required

Security Management Process

Risk analysis, risk management, sanction policy, information system activity review

Required

Assigned Security Responsibility

Designate a security official responsible for HIPAA compliance

Addressable

Workforce Security

Authorization, supervision, clearance procedures, termination procedures

Required

Information Access Management

Access authorization, access establishment, access modification

Addressable

Security Awareness Training

Security reminders, malware protection, login monitoring, password management

Required

Contingency Plan

Data backup, disaster recovery, emergency operations, testing, criticality analysis

45 CFR § 164.310

Physical Safeguards

Physical measures, policies, and procedures to protect electronic information systems and the buildings and equipment that hold them.

Addressable

Facility Access Controls

Contingency operations, facility security plan, access control, maintenance records

Required

Workstation Use

Policies for proper workstation use and environment

Required

Workstation Security

Physical safeguards restricting access to workstations

Required

Device & Media Controls

Disposal, media re-use, accountability, data backup/storage

45 CFR § 164.312

Technical Safeguards

Technology and the policies and procedures for its use that protect ePHI and control access to it.

Required

Access Control

Unique user ID, emergency access, auto logoff, encryption/decryption

Required

Audit Controls

Hardware, software, and procedural mechanisms to record system activity

Addressable

Integrity Controls

Mechanisms to authenticate ePHI and protect from improper alteration

Required

Person/Entity Authentication

Verify identity of persons or entities seeking access

Addressable

Transmission Security

Integrity controls and encryption for ePHI transmission

Frequently Asked Questions

Common questions on the HIPAA Security Rule, safeguards, and risk analysis.

What does the HIPAA Security Rule require?

The HIPAA Security Rule (45 CFR Part 160 and Subparts A and C of Part 164) requires covered entities and business associates to protect electronic Protected Health Information (ePHI) by implementing administrative, physical, and technical safeguards that ensure its confidentiality, integrity, and availability. Unlike the Privacy Rule, which covers PHI in any form, the Security Rule applies specifically to ePHI. It is enforced by the HHS Office for Civil Rights (https://www.hhs.gov/hipaa).

What is the difference between "required" and "addressable" specifications?

Each Security Rule implementation specification is labeled either Required or Addressable. Required specifications must be implemented as written. Addressable specifications are not optional — the entity must assess whether the specification is reasonable and appropriate for its environment, implement it if so, or document why it is not and put an equivalent alternative measure in place. "Addressable" means flexible, not skippable.

Is a Security Risk Assessment mandatory under HIPAA?

Yes. A risk analysis (Security Risk Assessment) is a required implementation specification under the Security Management Process administrative safeguard. Covered entities and business associates must conduct an accurate and thorough assessment of the risks to all ePHI, then implement risk-management measures to reduce those risks to a reasonable level. Missing or inadequate risk analysis is one of the most common findings in OCR enforcement actions.

Does HIPAA require encryption of ePHI?

Encryption is an addressable specification, not a flat requirement — but that does not make it optional. An entity must implement encryption where it is reasonable and appropriate, or document why not and adopt an equivalent safeguard. In practice, encrypting ePHI at rest and in transit is strongly advisable: properly encrypted ePHI that is lost or stolen generally falls within the breach "safe harbor" and is not considered unsecured PHI requiring breach notification.

How do Indian business associates implement the Security Rule?

Indian IT, BPO, and SaaS firms that handle US ePHI are business associates and are directly liable for the Security Rule. They implement the same administrative, physical, and technical safeguards — risk analysis, access controls, audit logging, encryption, workforce training, contingency planning — typically mapped onto an existing ISO 27001 or SOC 2 control environment. Tranquility Cybersecurity helps Indian business associates build this safeguard set and evidence it for US covered entities.

Continue your HIPAA research

Written By Expert Auditors

Saundhi Chauhan
Saundhi Chauhan
Lead Auditor
ISO 27001 Lead AuditorISO 27701 Lead Auditor
Surendra Pal Singh
Surendra Pal Singh
Chief Information Security Officer & Data Protection Officer
CISODPOCISAMCSEITILISO 27001 Lead AuditorISO 27701 Lead AuditorISO 42001 Lead Auditor
Last reviewed: June 2026Content verified by certified lead auditors

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