Access Establishment and Modification Policy (UBIT HIPAA)

Category: HIPAA Security
Responsible Office: UBIT HIPAA Compliance
Responsible Executive: Vice President and Chief Information Officer (VPCIO)
Approved By (Name/Title): J. Brice Bible, VPCIO

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CATEGORY: Administrative Safeguards
TYPE: Addressable Implementation Specification for Information Access Management
CITATION: 45 CFR 164.308(a)(4)(ii)(B)

The University at Buffalo Information Technology (UBIT) operates as a covered entity as defined by the U.S. Department of Health and Human Services Office of Civil Rights. HIPAA Regulation Text 45 CFR Part 164.308 (a)(4)(i) requires a covered entity to implement policies and procedures for authorizing access to ePHI that are consistent with the applicable subparts of the regulation.


UBIT implements policies and procedures, based upon its Access Authorization Policy, that establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process that can access ePHI.


This policy applies to all UBIT workforce members.


Workforce members: Adhere to policies and procedures as written.

HIPAA Security and Privacy Officer: Ensures implementation of policies and procedures for establishing, documenting, reviewing, and modifying a user’s right of access to a workstation, transaction, program, process, or other mechanism in conjunction with the Human Resources Director. 

Compliance Officer: Participates in ensuring security of ePHI is effective and enforced, in conjunction with the HIPAA Security and Privacy Officer.

Human Resource Director: Establishes and maintains an employee’s workforce status that used to grant authorized access to ePHI.

Contact Information

HIPAA Security and Privacy Officer

Vice President and Chief Information Officer
J. Brice Bible
517 Capen Hall
Buffalo, NY 14260
Phone: 716-645-7979

Date Approved: 12/6/2017