ORS 743.005 Protection of health information report

As used in this section:

“Covered entity” has the meaning given that term in ORS 192.556 but excludes state agencies.

“Protected health information” has the meaning given that term in ORS 192.556.

A covered entity that is required to file an annual financial statement under ORS 731.574 shall file with the Department of Consumer and Business Services, along with the financial statement, a protection of health information report. The report may be in the form of a letter, must be signed by the chief executive officer of the covered entity and must:

State the responsibility of the covered entity’s management to establish and maintain adequate safeguards and procedures for protecting the confidentiality of personally identifiable and protected health information that the covered entity retains in electronic and hard copy form;

Contain assurances that the signing officer has disclosed to the governing board of the covered entity:

All significant deficiencies in the design or operation of recordkeeping systems or controls that could adversely affect the covered entity’s ability to protect the confidentiality of personally identifiable and protected health information;

Any breaches of the security of personally identifiable and protected health information, whether material or not, that involve management or other employees who have a significant role in the covered entity’s recordkeeping systems or controls; and

All necessary steps that have been taken to address deficiencies in the design or operation of recordkeeping systems or controls and to resolve any material weaknesses identified to or by the covered entity’s auditors; and

Contain assurances that the signing officer has identified for the governing board of the covered entity any material weaknesses in the recordkeeping systems or controls.

The protection of health information report is confidential and not subject to disclosure under ORS 192.311 to 192.478.