Information Security Policy (SEC-POL-001)

1. Objective

The objective of this policy is to establish [Company Name]’s comprehensive Information Security Management System (ISMS) and define the overarching framework for protecting the confidentiality, integrity, and availability of all information assets. This policy serves as the foundation for all security controls and demonstrates [Company Name]’s commitment to safeguarding electronic Protected Health Information (ePHI), maintaining compliance with applicable regulations, and supporting business objectives through effective risk management.

2. Scope

This policy applies to all [Company Name] workforce members, including employees, contractors, temporary staff, and interns. It encompasses all information assets owned, operated, or managed by [Company Name], regardless of format (electronic, physical, or verbal), location (on-premises, cloud, or remote), or lifecycle stage (creation, processing, storage, transmission, or disposal). This policy also applies to all third parties, vendors, and business associates who access, process, or store [Company Name] information.

3. Policy

[Company Name] is committed to implementing and maintaining a comprehensive information security program that protects information assets and ensures regulatory compliance.

3.1 Information Security Governance

[Company Name] shall establish and maintain a formal information security governance structure to oversee the implementation and effectiveness of the ISMS.

• A designated Security Officer shall be appointed with ultimate responsibility for the information security program. The Security Officer shall report directly to executive leadership and have the authority to implement security controls across the organization.

• An Information Security Committee shall be established, comprising representatives from key business functions including executive leadership, IT, legal, compliance, human resources, and operations. The committee shall meet at least quarterly to review security performance, approve policy changes, and make strategic security decisions. Meeting minutes shall be documented and retained to provide an audit trail of all decisions.

• Information security objectives and requirements shall be integrated into all business processes, system development lifecycles, and vendor management activities.

• Security roles and responsibilities shall be clearly defined, documented, and communicated to all workforce members through formal job descriptions and training programs.

3.2 Risk Management Framework

[Company Name] shall implement a systematic approach to identifying, assessing, and managing information security risks.

• A formal risk assessment shall be conducted annually and whenever significant changes occur to the business environment, technology infrastructure, or regulatory landscape.

• Risk treatment decisions shall be documented and approved by appropriate management levels based on risk tolerance and business impact.

• Residual risks shall be monitored continuously, and risk treatment effectiveness shall be reviewed quarterly.

• A risk register shall be maintained to track all identified risks, treatment actions, and ownership assignments.

3.3 Information Classification and Handling

All information assets shall be classified according to their sensitivity level and handled in accordance with established security controls.

• Information shall be classified into defined categories (e.g., Public, Internal, Confidential, Restricted) based on the potential impact of unauthorized disclosure, modification, or destruction.

• Appropriate security controls shall be applied to each classification level, including access restrictions, encryption requirements, storage limitations, and disposal procedures.

• Data handling procedures shall comply with applicable privacy regulations, including HIPAA for ePHI and other data protection requirements.

• Information owners shall be designated for all critical information assets and shall be responsible for classification decisions and access approvals.

3.4 Access Control and Authentication

Access to information systems and data shall be controlled through formal processes that implement the principles of least privilege and separation of duties.

• All users shall be assigned unique identifiers and shall be authenticated before accessing any company systems or data.

• Multi-factor authentication shall be required for all systems containing sensitive information, including ePHI.

• Access rights shall be reviewed at least quarterly for systems containing Confidential or Restricted data and at least annually for all other systems. These reviews shall be documented.

• Privileged access shall be subject to additional controls, including time-limited sessions, enhanced monitoring, and separate administrative accounts.

3.5 Security Awareness and Training

All workforce members shall receive comprehensive security awareness training to understand their security responsibilities and recognize potential threats.

• New workforce members shall complete security awareness training within [Number, e.g., 30] days of hire.

• Annual refresher training shall be provided to all workforce members, with additional specialized training for roles with elevated security responsibilities.

• Training effectiveness shall be measured through assessments and security metrics.

• Targeted awareness campaigns shall be conducted to address emerging threats and security trends.

3.6 Incident Management

[Company Name] shall maintain the capability to detect, respond to, and recover from security incidents in a timely and effective manner.

• A formal incident response plan shall be maintained and tested regularly through tabletop exercises and simulations.

• All suspected security incidents shall be reported immediately through established channels and investigated according to documented procedures.

• Incident response activities shall be documented, and lessons learned shall be incorporated into security improvements.

• Regulatory notification requirements shall be met for incidents involving ePHI or other regulated data.

3.7 Business Continuity and Resilience

Critical business functions and information systems shall be protected through comprehensive business continuity and disaster recovery planning.

• Business impact assessments shall be conducted to identify critical functions and acceptable recovery timeframes.

• Backup and recovery procedures shall be implemented and tested at least annually to ensure data and system availability. Test results shall be documented.

• Alternative processing arrangements shall be established for critical systems to maintain operations during disruptions.

• Full recovery testing shall be performed annually and after significant infrastructure changes, with results documented and reviewed by the Information Security Committee.

3.8 Vendor and Third-Party Management

Security requirements shall be established and enforced for all vendors and third parties with access to [Company Name] information or systems.

• Security assessments shall be conducted before engaging vendors who will access, process, or store company information.

• Contractual agreements shall include specific security requirements, liability provisions, and audit rights.

• Business Associate Agreements (BAAs) shall be executed with all vendors who will handle ePHI.

• Vendor security performance shall be monitored through regular assessments and security questionnaires.

3.9 Compliance and Audit

[Company Name] shall maintain compliance with all applicable laws, regulations, and contractual obligations related to information security.

• Regular compliance assessments shall be conducted to verify adherence to HIPAA, SOC 2, and other applicable requirements.

• Internal audits shall be performed annually to evaluate the effectiveness of security controls and identify improvement opportunities.

• External audits and assessments shall be facilitated as required by regulatory or contractual obligations.

• Audit findings and corrective actions shall be tracked to completion and reported to appropriate management levels.

3.10 Continuous Improvement

The information security program shall be subject to continuous monitoring and improvement based on changing threats, business requirements, and industry best practices.

• Security metrics and key performance indicators (KPIs) shall be established and monitored to measure program effectiveness.

• Regular reviews of policies, procedures, and controls shall be conducted to ensure they remain current and effective.

• Industry threat intelligence and security advisories shall be monitored and incorporated into security planning.

• Employee feedback and suggestions for security improvements shall be encouraged and evaluated.

4. Standards Compliance

This policy is designed to comply with and support the following industry standards and regulations.

Policy Section	Standard/Framework	Control Reference
All	HIPAA Security Rule	45 CFR § 164.308(a)(1) - Security Management Process
3.1	HIPAA Security Rule	45 CFR § 164.308(a)(2) - Assigned Security Responsibility
3.2	HIPAA Security Rule	45 CFR § 164.308(a)(1)(ii)(A) - Conduct periodic risk assessment
3.4	HIPAA Security Rule	45 CFR § 164.308(a)(4) - Information Access Management
3.5	HIPAA Security Rule	45 CFR § 164.308(a)(5) - Security Awareness and Training
3.6	HIPAA Security Rule	45 CFR § 164.308(a)(6) - Security Incident Procedures
3.7	HIPAA Security Rule	45 CFR § 164.308(a)(7) - Contingency Plan
3.9	HIPAA Security Rule	45 CFR § 164.308(a)(8) - Evaluation
All	SOC 2 Trust Services Criteria	CC1.1 - Control Environment
3.1	SOC 2 Trust Services Criteria	CC2.1 - Communication and Information
3.2	SOC 2 Trust Services Criteria	CC3.1 - Risk Assessment Process
3.4	SOC 2 Trust Services Criteria	CC6.1 - Logical Access Security
3.6	SOC 2 Trust Services Criteria	CC7.1 - System Monitoring
3.7	SOC 2 Trust Services Criteria	A1.1 - Availability

5. Definitions

Business Associate Agreement (BAA): A written contract between a covered entity and a business associate as required by HIPAA, establishing permitted uses and disclosures of ePHI.

Electronic Protected Health Information (ePHI): Individually identifiable health information that is created, stored, transmitted, or maintained electronically.

Information Security Management System (ISMS): A systematic approach to managing sensitive company information to keep it secure, including policies, procedures, and controls.

Least Privilege: The security principle of restricting access rights for users to the bare minimum permissions needed to perform their work.

Risk Assessment: The process of identifying vulnerabilities and threats to information assets and determining the risk posed by those threats.

Security Incident: Any event that could result in unauthorized access to, or disclosure, modification, or destruction of information assets.

6. Responsibilities

Role	Responsibility
Executive Leadership	Provide strategic direction and resources for the information security program. Approve security policies and ensure accountability.
Security Officer	Develop, implement, and maintain the ISMS. Oversee security operations, incident response, and compliance activities.
Information Security Committee	Provide governance oversight, approve policy changes, and make strategic security decisions.
IT Department	Implement technical security controls, manage system security configurations, and support security operations.
Human Resources	Integrate security requirements into hiring processes, conduct background checks, and manage workforce security training.
Legal/Compliance Team	Ensure regulatory compliance, review contracts for security requirements, and manage legal aspects of security incidents.
Information Owners	Classify information assets, approve access requests, and ensure appropriate handling of sensitive data.
All Workforce Members	Comply with security policies, complete required training, and report security incidents or concerns.
Managers/Supervisors	Ensure their teams comply with security policies, approve access requests, and conduct regular access reviews.