EvidenceSheet
HIPAA Security Rule · Administrative

164.308(a)(3)(ii)(C) Termination Procedures (Addressable)

Implement procedures for terminating access to ePHI when employment ends or as required. NIST recommends time-bounded SLA, asset recovery, and HR-IT coordination.

Source: HIPAA Security Rule, 164.308(a)(3)(ii)(C). The statement above is our statement of the clause, read from the published text and cited so you can check it against the official text, not the instrument verbatim. Open HIPAA Security Rule in the compliance library.

Scope: Addressable, not optional: assess whether it is reasonable and appropriate; implement it, or document why not and adopt an equivalent alternative where reasonable (45 CFR 164.306(d)(3)).

Applies to covered entities and business associates. An addressable specification can be met by a documented, reasonable alternative.

5
artefacts
2
held by a system
1
at each review
moderate
to go live
Identity provider / directory
where the evidence lives
teal = a system already holds it · olive = produced at each review. To go live: easy when half or more of the artefacts are already held by a system, moderate from a quarter to a half, hard below a quarter.

These are the artefacts auditors commonly ask for on this requirement, our guidance rather than text from the standard. Your assessor decides what is sufficient in your context, and asks for samples across the period when a report covers one.

system holds itEvidence a system already holds

  • Account disablement SLA evidence · Identity provider / directory
  • Termination audit log · SIEM / log platform

periodic reviewEvidence produced at each review

  • Asset return records · HR system / LMS

governing documentDocuments that govern the control

  • Termination checklist · HR system / LMS
  • Documented addressable-specification decision: whether it is reasonable and appropriate in your environment, and if not, why, with the equivalent alternative adopted where one is · Policy repository / GRC workspace

First move

Start with the 2 of 5 artefacts that already live in a system (Identity provider / directory); keep the periodic reviews but log each one as a dated record with a named reviewer.

Common gaps auditors find

Do this for your whole sheet

Paste the rows you run your controls from and get this mapping for every control at once, with the periodic-review ones flagged and a first move per row. No account for the first run.

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164.308(a)(3)(ii)(B) Workforce Clearance Procedure (Addressable) · 164.308(a)(4)(i) Information Access Management (Standard)