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Office of Compliance and Audit Services

Policies & Procedures

Policy   Description PDF
Breach Notification - Notification of Protected Health Information (PHI) Breaches
This policy describes the assessment of possible breaches of PHI and outlines the proper notification procedures aimed to mitigate harm when a breach is determined.
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Compliance Reporting, Inquiries and Investigations

This policy reinforces participation in DMC’s Compliance Program, requires all individuals to abide by its directives and report concerns of non-compliance, and provides the framework for the inquiry, investigation and follow up of such reports.

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Compliance Training
This policy outlines the Compliance Training requirements and follow up processes for SUNY Downstate Medical Center's workforce. 
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Complying with the Deficit Reduction Act of 2005:  Detection & Prevention of Fraud, Waste & Abuse
This policy provides information regarding Federal & State statutes pertaining to false claims and statements, whistleblower protections under these laws and DMC's policies and procedures for detecting and preventing fraud, waste and abuse.
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Identity Theft Prevention

This policy identifies relevant patterns, practices, and forms of activity within "covered accounts" that are “red flags” signaling possible identity theft. It aims to prevent and mitigate identity theft as well as outline DMC's administration of the State University of New York (SUNY) Identity Theft Prevention Program.

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HIPAA Compliance

For Policies & Procedures relevant to UHB and UPB HIPAA Compliance, please visit the HIPAA Website.
Record Retention & Disposition

Information regarding the retention and disposition of official records of the campuses of the State University of New York:

SUNY System Policy

The following link outlines, by record type, the minimum retention requirements:

SUNY System Schedule for Health Information