What this control covers
Notice to Individuals. A covered entity shall, following the discovery of a breach of unsecured protected health information, notify each individual whose unsecured protected health information has been, or is reasonably believed by the covered entity to have been, accessed, acquired, used, or disclosed as a result of such breach. (2) Breaches treated as discovered. For purposes of paragraph (a)(1) of this section, 164.406(a), and 164.408(a), a breach shall be treated as discovered by a covered entity as of the first day on which such breach is known to the covered entity, or, by exercising reasonable diligence would have been known to the covered entity. A covered entity shall be deemed to have knowledge of a breach if such breach is known, or by exercising reasonable diligence would have been known, to any person, other than the person committing the breach, who is a workforce member or agent of the covered entity (determined in accordance with the federal common law of agency).
Why it matters
Risk is the language an executive team understands; this control connects technical reality to board-level decisions and budget allocation.
How to implement
AWS
Codify the policy intent as SCPs, AWS Config conformance packs, and Security Hub standards so the cloud enforces what the document says.
Azure
Codify in Azure Policy initiatives (built-in regulatory compliance for CIS, ISO 27001, SOC 2, HIPAA) and assign at management-group level.
On-premises
Maintain a policy library with a documented review cadence (annual minimum); store in your GRC tool with attestation tracking. Map each policy to controls so an audit pull cites the exact policy clause.
Evidence to collect
policy_document— A signed, version-controlled policy stating leadership intent and the named owner.
Signed policy or standard documents the safeguard. Focus: Notice to Individuals.
Quick checklist
- Workforce — Management / Individuals
- Information — Management / Individuals
- Person — Management / Individuals
- Other — Management / Individuals
- Policy — Management / Individuals
- Notice — Management / Individuals
Related articles on this site
- 164.312(c)(2) - Mechanism to authenticate electronic protected health information
- Ensure that 'Notify about alerts with the following severity' is set to 'High'
- CMMC 2.0 PE.1.131 Limit physical access to organizational information systems, equipment, and the respective operating environments to authorized individuals.
- HIPAA 164.308(a)(4)(i) Information Access Management