HIPAA Cloud Security Risk Assessment Checklist: Requirements, Controls, and Evidence

HIPAA Risk Assessment Requirements

This HIPAA Cloud Security Risk Assessment Checklist helps you evaluate how electronic protected health information (ePHI) is created, received, maintained, or transmitted in cloud services. It aligns with the Security Rule’s risk analysis and risk management standards (45 CFR 164.308(a)(1)(ii)(A)-(B)) and converts them into practical steps you can execute and prove with evidence.

Define scope and inventory ePHI

• List all cloud services, regions, accounts, and data stores that process ePHI, including backups and disaster recovery replicas.
• Map data flows end to end: patient intake, APIs, integrations, analytics, and exports. Include identities, keys, and pipelines.
• Classify data by sensitivity and residency requirements; document where ePHI is stored, processed, and transmitted.

Apply a risk analysis methodology

• Identify threats and vulnerabilities for each asset and data flow (misconfiguration, privilege misuse, insecure APIs, data exfiltration).
• Estimate likelihood and impact, assign risk ratings, and record assumptions and compensating controls.
• Select risk treatments: mitigate, accept (with executive sign‑off), transfer, or avoid; set target dates and owners.
• Document results in a risk register with traceability to controls and verification tests.

Using a consistent risk analysis methodology strengthens your security management process and makes decisions reproducible across teams and audits.

Governance and shared responsibility

• Appoint a security official; define roles for privacy, compliance, and engineering leads.
• Document the cloud shared responsibility model, showing what your team owns versus what the cloud service provider (CSP) operates.
• Execute and maintain Business Associate Agreements (BAAs) with all relevant vendors and subprocessors.

Review cadence and documentation

• Reassess risks at least annually, and upon major architectural changes, new services, or security incidents.
• Preserve analysis, decisions, and approvals for a minimum of six years to meet documentation requirements.

Administrative Safeguards

Security management process

• Translate risks into control objectives and implementation plans; track status and residual risk.
• Establish policies for acceptable use, remote access, vulnerability management, change management, and secure software development.
• Schedule periodic reviews of system activity, including audit logs and access reports.

Workforce security and training

• Grant access based on job function and least privilege; remove access promptly when roles change.
• Deliver role‑based training on handling ePHI, phishing, incident reporting, and secure use of cloud resources.
• Apply a sanctions policy for violations and record outcomes.

Information access management

• Use access control mechanisms such as SSO with MFA, privileged access management, and break‑glass procedures with enhanced monitoring.
• Perform periodic access certifications for applications, databases, and cloud control planes.
• Document approvals for exceptions and time‑bound elevated access.

Contingency planning

• Define backup, disaster recovery, and business continuity plans with RPO/RTO targets mapped to ePHI systems.
• Test restores and failovers; document results, gaps, and corrective actions.
• Ensure protected backups (encryption, immutability) and geo‑redundancy consistent with data residency rules.

Security incident procedures

• Maintain an incident response plan with triage, investigation, containment, eradication, and recovery steps.
• Integrate ticketing and communications playbooks for potential breaches involving ePHI.
• Capture chain of custody and evidence artifacts to support audit trail integrity and post‑incident reviews.

Evaluation and third‑party oversight

• Conduct periodic technical and non‑technical evaluations of cloud environments against HIPAA safeguards.
• Perform third‑party risk assessments; review CSP assurances, penetration tests, and relevant audit reports under BAAs.

Physical Safeguards

Shared responsibility considerations

In cloud, the CSP operates facilities, power, and environmental controls; you control how services are configured and accessed. Your checklist should capture evidence that the CSP’s controls are in place while demonstrating how your configurations protect ePHI.

Facility access controls

• Document region selection and data residency; restrict deployments to approved regions.
• Request and archive provider assurances available under the BAA regarding data center security and visitor controls.
• Define emergency access procedures for recovery scenarios that still preserve least privilege.

Workstation use and security

• Harden endpoints with disk encryption, screen locks, EDR, and MDM; prohibit local storage of ePHI unless justified and encrypted.
• Set policies for remote work, secure Wi‑Fi, and prohibited software.

Device and media controls

• For cloud storage, implement lifecycle rules, secure deletion, and immutability for critical backups.
• For on‑prem devices, sanitize and dispose of media per a documented process; retain certificates of destruction.
• Control snapshot exports and removable media; monitor and log data transfers.

Technical Safeguards

Access control mechanisms

• Enforce unique user IDs, MFA, and just‑in‑time privileged access with short‑lived credentials.
• Use role‑based access control, attribute‑based policies, and permission boundaries to ensure minimum necessary access.
• Configure automatic logoff and session timeouts for consoles and applications handling ePHI.

Integrity, authentication, and transmission security

• Protect data integrity with hashing, checksums, digital signatures, and database integrity controls.
• Authenticate users and services via SSO, OAuth/OIDC, short‑lived tokens, and mutual TLS where appropriate.
• Encrypt data in transit with modern TLS; prefer private connectivity (private endpoints, VPN, or IPsec) for sensitive flows.

System and network protections

• Segment environments (prod, dev, test), isolate workloads with VPCs, and restrict east‑west traffic using security groups and firewalls.
• Harden images, patch regularly, and automate configuration baselines with policy enforcement and drift detection.
• Apply web application and API protections, secrets management, and runtime threat detection.

Encryption Requirements

Encryption is an addressable implementation specification under the Security Rule, but in cloud environments it is typically reasonable and appropriate. Treat it as a default requirement unless a documented, justified alternative provides equivalent protection.

Data at rest

• Enable storage‑level encryption for disks, object stores, databases, and backups using strong data encryption standards (for example, AES‑256).
• Use envelope encryption and customer‑managed keys where feasible; limit access to key material and logs.
• Protect snapshots and replicas; prevent unencrypted exports.

Data in transit

• Enforce TLS 1.2+ (prefer TLS 1.3) for all external and internal endpoints handling ePHI.
• Disable weak ciphers and protocols; require HSTS for web apps and mutual TLS for service‑to‑service where risk warrants.
• Use VPN or private links for administrative access and data synchronization jobs.

Key management and operations

• Centralize keys in a managed KMS or HSM; separate key custodians from application owners.
• Rotate keys on a defined schedule and upon personnel or control changes; monitor for unauthorized use.
• Secure backups of keys, maintain escrow procedures, and document key destruction when retiring datasets.

Field‑level protections

• Apply application‑level encryption, tokenization, or format‑preserving encryption for especially sensitive fields.
• Minimize ePHI in logs and analytics; use de‑identification or pseudonymization when possible.

Audit Controls

Comprehensive logging coverage

• Capture control‑plane activity (administrative actions), data‑plane access (reads/writes), network flows, OS events, database queries, and application logs.
• Record who did what, when, from where, and to which ePHI resource; correlate identities across systems.
• Centralize logs in a secure, access‑controlled repository integrated with your SIEM.

Audit trail integrity and retention

• Protect audit trail integrity with immutability (WORM/object lock), tamper‑evident hashing, and time synchronization.
• Define retention aligned to detection and investigation needs; many organizations align with the six‑year documentation rule for summary records and keep detailed logs for a risk‑based period.
• Continuously test log completeness and integrity verification procedures.

Monitoring, alerting, and review

• Implement detections for anomalous access, encryption disabled, public exposure, privilege escalations, and data exfiltration.
• Run scheduled reviews of privileged activity, failed logins, and policy exceptions; track findings to remediation.
• Maintain separation of duties: engineering generates logs, security monitors, compliance verifies evidence.

Evidence Retention

What to retain

• Risk analysis outputs, risk register, and risk treatment plans.
• Policies, procedures, and revisions forming your security management process.
• Access reviews, user provisioning records, MFA attestations, and role definitions.
• BAAs and vendor due‑diligence assessments.
• System configurations, baseline templates, and change approvals.
• Vulnerability scans, penetration tests, code review results, and patch reports.
• Audit logs or summaries demonstrating audit trail integrity and monitoring actions.
• Backup/restore tests, DR exercises, and incident response records.
• Encryption configurations, key management logs, and key lifecycle records.

Retention periods and ownership

• Retain required HIPAA documentation for at least six years from creation or last effective date (45 CFR 164.316(b)).
• Assign owners for each evidence type; define where it lives, who can access it, and how long it is kept.
• Apply legal holds when incidents or investigations involve ePHI.

Storage, integrity, and retrieval

• Use a secure repository with versioning, access logging, and strong encryption.
• Apply checksums or digital signatures; periodically verify integrity of archived evidence.
• Maintain a control‑to‑evidence traceability matrix to accelerate audits and demonstrate compliance documentation retention.

Conclusion

By following this HIPAA Cloud Security Risk Assessment Checklist—covering requirements, controls, and evidence—you align cloud practices to HIPAA’s administrative, physical, and technical safeguards. Clear access control mechanisms, strong encryption, rigorous audit controls, and disciplined documentation create measurable assurance that ePHI is protected.

FAQs.

What are the key HIPAA requirements for cloud security risk assessments?

Conduct and document a thorough risk analysis of how ePHI is handled in cloud services, implement risk‑based controls, maintain policies and procedures, manage workforce access, formalize BAAs with vendors, and continuously monitor and reassess. Evidence should tie risks to controls and demonstrate ongoing effectiveness through reviews, testing, and incident handling.

How should covered entities implement encryption for ePHI in the cloud?

Treat encryption as the default: enable strong data encryption standards for data at rest (for example, AES‑256) and enforce TLS 1.2+ for data in transit. Centralize keys in KMS/HSM, separate duties, rotate keys regularly, monitor key usage, and protect backups and snapshots. If an alternative to encryption is used, document the rationale and compensating controls as part of your risk analysis methodology.

What types of evidence must be retained to demonstrate HIPAA compliance?

Maintain the risk analysis and risk management plan, policies and procedures, BAAs, access control records, training and sanctions records, configuration baselines, vulnerability and patch reports, audit logs or summaries proving audit trail integrity, backup/restore and DR tests, incident reports, and encryption/key management artifacts. Keep required documentation for at least six years, with secure storage and integrity checks to ensure reliability during audits.