HIPAA (45 CFR Part 164) 164.504(g) — Requirements for a covered entity with multiple covered functions

What this control requires

Requirements for a covered entity with multiple covered functions. (1) A covered entity that performs multiple covered functions that would make the entity any combination of a health plan, a covered health care provider, and a health care clearinghouse, must comply with the standards, requirements, and implementation specifications of this subpart, as applicable to the health plan, health care provider, or health care clearinghouse covered functions performed. (2 )A covered entity that performs multiple covered functions may use or disclose the protected health information of individuals who receive the covered entity's health plan or health care provider services, but not both, only for the purposes related to the appropriate function being performed.

In plain English

Requirements for a covered entity with multiple covered functions. In practice, this means you can prove you information requirements-level controls on a defined cadence.

Why it matters

HIPAA non-compliance is a strict-liability matter: OCR civil monetary penalties are assessed per-record per-violation (up to USD 1.9 million per identical-violation calendar year as of 2024), and willful neglect can trigger criminal referral.

What an auditor looks for

HHS OCR investigators and SOC-2+HIPAA auditors look for the specific 45 CFR § citation, whether the safeguard is required vs addressable (and if addressable, the documented decision), the implementation specification, the workforce member responsible, and the records that show it runs.

Within Privacy Rule, the assessor will trace your implementation back to the catalogue reference (§ 164.504(g)) and look for objective evidence on the latest two assessment cycles.

How to implement

Policy Management

Docs. Keep each policy in version-controlled Markdown alongside the code that implements it; ship a signed PDF snapshot at each annual review and link the SHA into the SoA.

Operational checklist

• Information. Document the trigger, the owner and the cadence.
• Requirements. Document the trigger, the owner and the cadence.
• Policy. Document the trigger, the owner and the cadence.
• Scope: requirements, management, individuals, policy, applicable, standards.

Evidence to collect

• Policy Document. A signed and version-controlled policy / standard / procedure document.

Signed policy or standard documents the safeguard. Focus: Requirements for a covered entity with multiple covered functions.

Common pitfalls

• Policies that no engineer has read; the version in Confluence drifts from the version that's actually being enforced.

How it maps to other frameworks

Computed from shared tags, control component and key-operation subjects — handy when you are reconciling controls across an audit.

• NIST SP 800-53 Rev. 5 PS-4(1) — Post-Employment Requirements
• ISO/IEC 27001:2022 A.8.26 — Application security requirements
• BSI C5:2020 SP-01 — Documentation, communication and provision of policies and instructions
• SOC 2 (2017 TSC) CC2.3 — External Communication on Internal Control Matters
• NIST SP 800-171 Rev. 3 3.5.11 — Authentication Feedback

Related controls in HIPAA (45 CFR Part 164)

• § 164.502(f) — Deceased individuals
• § 164.530(d)(1) — Complaints to the Covered Entity
• § 164.502(j)(2) — Disclosures by workforce members who are victims of a crime
• § 164.524(e) — Documentation
• § 164.522(b)(1) — Confidential Communications Requirements
• § 164.530(c) — Safeguards

References

• U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
• Catalogue identifier: § 164.504(g)

Topics: governance riskpolicy management