What evidence do auditors commonly ask for on 164.308(a)(4)(ii)(C) Access Establishment and Modification (Addressable)?

Quarterly access recertification reports; Modification approval records; Privileged access management logs; Manager attestations; 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.

HIPAA Security Rule · Administrative

`164.308(a)(4)(ii)(C)` Access Establishment and Modification (Addressable)

Implement policies that document, review, and modify a user's right of access. NIST recommends periodic recertification and just-in-time elevation for privileged tasks.

Source: HIPAA Security Rule, 164.308(a)(4)(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.

artefacts

held by a system

at each review

hard

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

Privileged access management logs · Identity provider / directory

periodic reviewEvidence produced at each review

Quarterly access recertification reports · Identity provider / directory
Modification approval records · Identity provider / directory
Manager attestations · Identity provider / directory

governing documentDocuments that govern the control

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

Mostly documents and reviews. Pull the 1 system-held artefact from your Identity provider / directory on a schedule; put the documents under version control with an owner and review date, and log each review as a dated record with a named reviewer.

Common gaps auditors find

Recertification not performed
Privileged accounts not reviewed
No tracking of access changes over time

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.

Build my evidence sheet

164.308(a)(4)(ii)(B) Access Authorization (Addressable) · 164.308(a)(5)(i) Security Awareness and Training (Standard)