ALL security breaches MUST be reported to the Centers for Medicare and Medicaid Services (CMS).

Patient Confidentiality and HIPAA Guidelines

Communication through email correspondence is the standard for most facilities in the Network. Please be advised that email correspondence to the Network is NOT SECURE and does not meet the guidelines established by the Health Insurance Portability and Accountability Act (HIPAA) for transmission of Protected Health Information (PHI). Per the Centers for Medicare and Medicaid Services (CMS), communication of Personally Identifiable Information (PII) and PHI via Email is classified as a security incident and must be reported to CMS by the Network office.

As per CMS guidelines, if we receive PII or PHI on any patient via email, this breach must be reported to the sender and the facility administrator via email, and to CMS through the use of the CMS Incident Handling Actions. An investigation will be done by a designated CMS QualityNet (QNet) security staff member. Depending on the type and severity of the incident, internal procedures and/or external agencies will be notified as required by law. Upon receipt of our notice from the Network, it is your facility’s responsibility to notify your organization’s HIPAA compliance officer and to follow the guidelines established by your institution to comply with HIPAA mandates.


United States Department of Health and Human Services (DHHS)

  • HIPAA Training Materials: Link
  • Health Information Privacy: Link
  • Understanding Patient Safety Confidentiality: Link

Centers for Medicare and Medicaid Services (CMS) HIPAA

  • HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules: Guide
  • National Provider Identifier Standard (NPI): Link

QualityNet Users

  • Identifying and Safeguarding Personally Identifiable Information (PII) Training Module: Link