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Professional Integrity Office

HIPAA Training


To ensure that all USF Health credentialed providers, fellows, residents, students, staff, and all employees of the USF HIPAA covered health care components (collectively, "Workforce Members") with access to protected health information (PHI) receive HIPAA Privacy training and are familiar with HIPAA regulations and USF Health policies related to security and confidentiality of patient information. See 45 C.F.R. § 164.530

Standard Practices

Workforce Members shall complete the USF Health online HIPAA Privacy training prior to having access to Protected Health Information (“PHI”). Workforce members are to receive pertinent role-specific training as part of their orientation/onboarding in accordance with departmental/unit procedures.


  1. The hiring manager/supervisor is responsible for ensuring that the Workforce Member completes the USF Health online HIPAA training.
  2. Access to the electronic medical record and/or the patient management system is contingent upon completion by the Workforce Member of the required online HIPAA training.
  3. Training will be completed within a reasonable time, but no later than within 10 days, after the Workforce Member joins the USF Health HIPAA Covered Entity. Training then must occur every fiscal year thereafter (deadline date is June 30 for annual training.)
  4. Role-based training is to be provided to Workforce Members involved in performing duties related to the USF HIPAA Covered Component’s responsibilities, including those addressed in the Joint Notice of Privacy Practices and Notice of Organized Health Care Arrangement. This includes Health Information Management; QSR Patient Advocate; and USFPG Call Center and Revenue Performance staff. Such training is to be provided as part of new Workforce Member orientation and as part of the required annual HIPAA training.
  5. The annual training includes HIPAA Privacy and Computer & Information online modules via SABA and any applicable role based training.
  6. Additional training within a reasonable time will be required of each Workforce Member whose functions are affected by a material change in the applicable regulations.
  7. The online training data shall be maintained within the USF Health Learning Management System, with reports available to management within all units.