164.524(a)(3)·medium·Component: Privacy RuleWhat this control requires
Standard: Access to protected health information. (3) Reviewable grounds for denial. A covered entity may deny an individual access, provided that the individual is given a right to have such denials reviewed, as required by paragraph (a)(4) of this section, in the following circumstances: (i) A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person; (ii) The protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or (iii) The request for access is made by the individual's personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.
In plain English
Standard: Access to protected health information. In practice, this means you can prove you information management-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 (§ 164.524(a)(3)) 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.
- Person. Document the trigger, the owner and the cadence.
- Other. Document the trigger, the owner and the cadence.
- Policy. Document the trigger, the owner and the cadence.
- Personal. Document the trigger, the owner and the cadence.
- Scope: management, policy, i, section, ii, denial, iii.
Evidence to collect
- Policy Document. A signed and version-controlled policy / standard / procedure document.
Signed policy or standard documents the safeguard. Focus: Reviewable grounds for denial.
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.
- BSI C5:2020 SP-01 — Documentation, communication and provision of policies and instructions
- ISO/IEC 27001:2022 A.5.5 — Contact with authorities
- SOC 2 (2017 TSC) CC2.3 — External Communication on Internal Control Matters
- NIST SP 800-53 Rev. 5 CP-7(2) — Accessibility
- NIST SP 800-171 Rev. 3 3.13.15 — Session Authenticity
Related controls in HIPAA (45 CFR Part 164)
- § 164.522(a)(2) — Terminating a Restriction
- § 164.530(d)(2) — Complaints to the Covered Entity
- § 164.530(g) — Refraining from Intimidating or Retaliatory Acts
- § 164.524(a)(2) — Unreviewable grounds for denial
- § 164.526(a)(2) — Denying the Amendment
- § 164.528(d) — Documentation
References
- U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
- Catalogue identifier:
§ 164.524(a)(3)
Topics: governance riskpolicy management