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Certified in Healthcare Privacy and Security Practice Test

AHIMA-CHPS test Format | Course Contents | Course Outline | test Syllabus | test Objectives

Exam Code: AHIMA-CHPS
Exam Name: Certified in Healthcare Privacy and Security (CHPS)
Number of questions: 150 total questions (125 scored + 25 pretest items)
Time allotted: 3 hours- 25 minutes of test time (total appointment time 3 hours- 30 minutes including memorizing the agreement)
Passing score: 300 (on the AHIMA standardized scale)

- Ethical- Legal- and Regulatory Issues/ Environmental Assessment
- Identify responsibilities as a privacy officer and/or security officer
- Serve as a resource (provide guidance) to your organization regarding privacy and security laws-regulations- and standards of accreditation agencies to help interpret and apply the standards
- Apply preemption principles to ensure compliance with state regulations that are applicable to privacy
- Evaluate the privacy and security policies related to health information exchanges
- Demonstrate privacy and security compliance with documentation- production and retention as requiredby State and Federal law as well as accrediting agencies
- Analyze the impact of access to protected health information (PHI) during a public health emergency

– Privacy and Security Program Management and Administration
- Manage the distribution process of the organization’s Notice of Privacy Practices
- Manage the process for requests for patients’ rights as outlined in the Notice of Privacy Practices (e.g.-restrictions- amendments- etc.)
- Manage contracts and business associate relationships and secure appropriate agreements related toprivacy and security (e.g.- business associate agreement [BAA]- service level agreement [SLA]- etc.)
- Evaluate and monitor the facility security plan to safeguard unauthorized physical access to information-and to prevent theft or tampering
- Establish a preventative program to detect and prevent privacy/security breaches
- Develop- deliver- evaluate- and document training and awareness on information privacy and security toprovide an informed workforce
- Educate workforce members on the changes to organizational policies- procedures- and practices relatedto privacy and security
- Collaborate with appropriate organization officials to verify that information used or disclosed for researchpurposes complies with organizational policies and procedures and applicable privacy regulations
- Manage appropriate de-identification processes
- Assess and communicate risks and ramifications of privacy and security incidents to a designatedorganizational leadership- including those by business associates
- Verify that requesters of protected information are authorized and permitted access to the protectedhealth information (PHI)
- Apply the “minimum necessary” standard when creating- documenting- and communicating protectedhealth information (PHI)
- Define HIPAA-designated record sets for the organization in order to appropriately respond to a request forrelease of protected health information (PHI)
- Identify information and record sets requiring special privacy protections
- Manage disclosures for marketing and fundraising related to protected health information (PHI)

- Information Technology/Physical and Technical Safeguards
- Develop and manage an organization’s information security plan- taking into consideration 45 CFR 164.306
- Manage policies- procedures- and rules to protect the integrity- availability- and confidentiality ofcommunication of health information across networks
- Ensure reasonable safeguards to reduce incidental disclosures and prevent privacy breaches
- Collaborate in the development of a business continuity plan for planned downtime and contingency planning for emergencies and disaster recovery
- Evaluate- select- and implement information privacy and security solutions
- Monitor compliance with the security policies and ensure compliance with technical- physical- and administrative safeguards
- Assess the risk to and criticalities of new information systems which contain protected health information (PHI)
- Assess and monitor physical security mechanisms to limit the access of unauthorized personnel to facilities- equipment- and information
- Assess and monitor technical security mechanisms to control access and protect electronic protected health information (PHI)
- Perform ongoing risk assessments for existing information systems which contain protected health information (PHI)
- Ensure appropriate technologies are used to protect information received from or transmitted to external users
- Manage the process for verifying and controlling access authorizations- authentication mechanisms- and privileges including emergency access
- Identify event triggers for abnormal conditions within a network system (e.g.- intrusion detection- denial of service- and invalid log-on attempts)
- Manage the media control practices that govern the receipt- removal- re-use- or disposal (internal and external destruction) of any media or devices containing sensitive data
- Develop and maintain the inventory of software- hardware- and all data to protect information assets and to facilitate risk analysis

- Investigation- Compliance- and Enforcement
- Monitor and assess compliance with state and federal laws and regulations on a routine basis related to privacy and security to update organizational practices- policies- procedures- and training of workforce
- Develop policy and procedure for breach notification
- Establish an incident/complaint investigation process- and develop a response plan to mitigate a privacy or security incident
- Ensure workforce is knowledgeable on how to report a potential privacy or security incident
- Enforce privacy and security policies- procedures- and guidelines to facilitate compliance with federal- state- and other regulatory or accrediting bodies
- Monitor and audit access to protected health information (PHI)
- Perform risk assessment for breach notification
- Coordinate the organization’s response to inquiries and investigations from external entities relating to privacy and security to provide response consistent with organizational policies and procedures within the required timeframe
- Notify appropriate individuals/agencies/media within time frame for breach notification
- Maintain the appropriate documentation for breach notification

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Question: 1117
A policy requires regular review of user privileges and immediate removal of access for terminated
employees. What compliance aspect does this safeguard primarily support?
A. Integrity of systems
B. Availability of data
C. Confidentiality and security of ePHI
D. Encryption key management
Answer: C
Explanation: Regular review and prompt revocation of access for terminated employees prevent
unauthorized ePHI access, supporting confidentiality and overall security.
Question: 1118
A state law mandates breach reporting within 10 days, while HIPAA requires notification within 60 days.
During a compliance review, which policy is best to ensure regulatory adherence?
A. Follow the 10-day state breach reporting requirement
B. Adhere only to the HIPAA 60-day requirement due to federal preemption
C. Combine the timelines and notify within 35 days, the average of both
D. Notify breaches only when requested by regulators
Answer: A
Explanation: The organization must comply with the more stringent 10-day state notification requirement
as it does not conflict with HIPAA but enhances timely breach reporting. HIPAA sets minimum
standards and states can require faster notification timelines.
Question: 1119
Following a 2024 phishing simulation exposing 40% click rates among staff, a cardiology practice in
2026 updates its training per OCR's October newsletter, but the risk assessment reveals persistent weak
passwords on shared physical kiosks in test rooms. What technical safeguard enforces credential
hygiene at endpoints?
A. Monitor password spray attempts with account lockouts after three failed tries across devices.
B. Integrate adaptive authentication escalating to MFA based on login location and time patterns.
C. Rotate default kiosk passwords monthly via centralized management with complexity enforcement.
D. Deploy passwordless authentication using FIDO2 security keys for kiosk logins with biometric
fallbacks.
Answer: D
Explanation: Deploying passwordless authentication using FIDO2 security keys for kiosk logins with
biometric fallbacks eliminates weak password vulnerabilities, aligning with HIPAA �164.312(d)
authentication and NPRM's MFA emphasis for phishing-prone environments. High click rates indicate
human factors risks, as in 2024's five ransomware settlements. FIDO2 provides phishing-resistant
hardware tokens, biometrics add physical layer, outperforming rotations' burden. For cardiology kiosks,
this streamlines workflows, supports physical hygiene, and drives compliance via key audits, reducing
initiative penalties.
Question: 1120
A hospital security team recently discovered several unauthorized attempts to access patient health
records via terminal stations located in the waiting area. What is the best initial step to respond and
reduce future risk of physical access to sensitive information in such areas?
A. Reconfigure terminals to automatically log off after short idle times and restrict guest access
B. Increase physical patrols and surveillance cameras in waiting and common areas
C. Apply biometric authentication exclusively at all terminal stations in the hospital
D. Relocate all terminal stations away from public waiting areas into secured rooms
Answer: A
Explanation: Reconfiguring terminals for automatic logoff after short idle periods and restricting guest
access directly addresses unauthorized physical access via unattended terminals in public spaces, which is
a common physical safeguard. Increasing surveillance is useful but less direct. Moving terminals may
disrupt workflow, and biometric authentication only at terminals may not be feasible or enough without
administrative controls like automatic logoff.
Question: 1121
A hospital network experiences multiple incidents of Denial of Service (DoS) attacks targeting its EHR
system. Which technical safeguard is best suited to mitigate this threat?
A. Increase bandwidth capacity to absorb attack traffic without filtering
B. Disable all remote access to reduce attack surface
C. Implement intrusion prevention systems (IPS) with real-time traffic analysis and blocking rules
D. Schedule system maintenance during expected attack windows to minimize impact
Answer: C
Explanation: IPS devices detect and block malicious network traffic, effectively mitigating DoS attacks
by stopping harmful packets before they impact the system. Disabling remote access may reduce
functionality unnecessarily. Increasing bandwidth does not address the root attack and scheduling
maintenance does not prevent attacks.
Question: 1122
A academic medical center collaborating on a multi-institutional AI-driven research project in 2026 must
define its DRS to respond to participant requests for PHI access, including AI-analyzed imaging data
from mental health studies. The project involves BAs handling ePHI with potential special protections for
mental health and substance use data under aligned Part 2 rules. latest OCR guidance stresses minimum
necessary disclosures for research preparatory activities. During a mock audit, inconsistencies arise in
classifying AI outputs as DRS components, risking impermissible uses. What is the optimal strategy for
the privacy officer to manage DRS definition, incorporating physical safeguards and regulatory
compliance?
A. Classify AI outputs outside the DRS, limit BA access to de-identified data, and secure physical
storage with locked facilities for original records.
B. Define DRS to include only raw data, permit full AI disclosures to BAs without limits, and rely on
video surveillance for physical security.
C. Exclude mental health data from DRS for research, update BA contracts for Part 2 consents, and use
standard keycard systems for physical safeguards.
D. Include AI outputs in the DRS if used for decisions, require data use agreements with minimum
necessary clauses, and implement biometric access for physical research labs.
Answer: D
Explanation: Designated record sets (DRS) encompass records used to make decisions about individuals,
including research records if they influence care (�164.501), and AI outputs qualify if integrated into
treatment planning. The 2024 42 CFR Part 2 alignment permits HIPAA-like disclosures for
substance/mental health data with consents, but preparatory research requires minimum necessary under
�164.502(b). Special protections apply, necessitating identification in program policies. Physical
safeguards under Security Rule �164.310 include facility access controls like biometrics for high-risk
areas. This strategy ensures DRS accuracy for access requests (�164.524), compliant BA management
(�164.314), and regulatory adherence, mitigating enforcement risks amid OCR's 2026 focus on AI-related
breaches.
Question: 1123
A physician�s practice suspects a breach due to a lost unencrypted laptop containing patient data. Which
of the following steps must be taken in the initial response?
A. Confirm if the data on the laptop is accessible and encrypted before proceeding
B. Immediately notify the media to proactively manage public perception
C. Inform all patients regardless of the breach risk assessment outcome
D. Ignore the incident if the laptop is suspected to be lost temporarily
Answer: A
Explanation: The key initial step is to determine whether the data on the laptop is accessible and if it was
encrypted because encryption can mitigate the requirement to notify individuals if data is rendered
unusable. Notification decisions depend on this assessment. Media notification or notifying all patients
without assessment violates best practices.
Question: 1124
An IT auditor finds that emergency access credentials are shared among multiple trusted users without
individual identification. What is the primary security issue and recommended corrective action?
A. Lack of accountability; assign unique credentials with individual audit trails
B. Simplified emergency response; continue current practice
C. Cost saving; shared credentials reduce management overhead
D. No issue as long as emergency access is restricted physically
Answer: A
Explanation:
Sharing credentials obscures individual actions and accountability, violating HIPAA requirements for
access controls and auditability. Unique credentials with individual logging ensure traceability and secure
emergency access management. Convenience or cost saving should not override security.
Question: 1125
Following a 2026 phishing incident at a Florida telehealth provider, the privacy officer uncovers that the
incident stemmed from inadequate workforce training on recognizing social engineering attacks, violating
both HIPAA administrative safeguards and Florida's strict data privacy laws on breach prevention. What
is the officer's primary duty in guiding the organization's response?
A. Solely report the incident to HHS without internal remediation
B. Develop and deliver comprehensive training programs interpreting HIPAA's workforce security
requirements alongside Florida's more protective standards to prevent recurrence
C. Rely on external consultants for all training updates
D. Limit response to affected patients only
Answer: B
Explanation: As a resource for regulatory interpretation, the privacy officer must design targeted training
under HIPAA's Security Rule (45 CFR � 164.308(a)(5)) to address phishing threats, incorporating
Florida's Information Protection Act mandates for proactive breach prevention training that exceed
HIPAA's baselines. This includes simulations, policy reinforcement, and preemption analysis to ensure
state laws' stricter employee accountability measures are applied, thereby enhancing organizational
resilience and ethical stewardship of PHI in a high-risk telehealth environment.
Question: 1126
Which compliance enforcement mechanism requires prompt investigation and effective mitigation actions
when monitoring reveals potential unauthorized PHI access?
A. HIPAA Security Rule audit controls provision
B. OSHA workplace safety inspections
C. FDA post-market surveillance regulations
D. CMS mandatory reporting for fraud only
Answer: A
Explanation: The Security Rule mandates audit controls to detect, investigate, and mitigate unauthorized
access to PHI. OSHA and FDA regulations address different domains. CMS fraud reporting is related
but not specific to technical access monitoring.
Question: 1127
A covered entity plans to release PHI for marketing purposes. What documentation is required to ensure
compliance?
A. Only a patient notification, no written authorization necessary
B. An internal memo approving the marketing strategy
C. Documentation of verbal consent from the individual
D. A valid written authorization from the individual specifying the marketing disclosure
Answer: D
Explanation: HIPAA strictly requires valid, written authorization specifying the marketing purpose before
PHI can be disclosed for marketing. Internal memos and verbal consents are insufficient.
Question: 1128
During an IT security assessment, it is found that no encryption is applied to laptops used by field nurses
containing PHI. What technical safeguard would be most appropriate?
A. Use of complex passwords only without additional controls
B. Software firewalls installed without encryption
C. Full disk encryption on all portable devices to protect ePHI at rest
D. Encouraging nurses to carry devices only during work hours
Answer: C
Explanation: Full disk encryption protects data if the device is lost or stolen, a critical requirement for
portable devices with PHI. Firewalls and passwords alone do not protect data at rest. Behavioral controls
like timing do not ensure security.
Question: 1129
Which of the following roles within an organization is most responsible for ensuring policies and
procedures for breach notification comply with federal and state laws?
A. Chief Information Officer (CIO)
B. Privacy Officer or Compliance Officer
C. Director of Nursing
D. Chief Financial Officer (CFO)
Answer: B
Explanation: The Privacy Officer or Compliance Officer is primarily responsible for ensuring that
policies, including breach notification, comply with applicable laws and regulations. Although CIO and
other leadership may support the process, compliance roles oversee regulatory adherence. Directors of
nursing and CFOs have operational and financial roles, respectively, but not primary compliance
responsibilities.
Question: 1130
In 2026 research collab, DRS excludes trial data with infectious PHI. BA shares fundraising. IRB flags.
What?
A. Exclude, permit share, ignore IRB.
B. Include with flags, auth share, address IRB.
C. Non-exclude, no auth.
D. Partial, delayed.
Answer: B
Explanation: Trial DRS; auth, IRB compliance.
Question: 1131
A long-term care facility in 2026, amid OCR's 2024-2025 audits, discovers resident monitoring cameras
streaming ePHI-tagged videos over unsegmented IoT networks, vulnerable to Mirai-like botnets per
pentest. The assessment rates IoT as emerging high-threat. What technical safeguard isolates these
devices?
A. Upgrade cameras to HIPAA-compliant models with built-in encryption and automatic firmware
updates.
B. Create dedicated IoT VLANs with micro-segmentation firewalls blocking outbound traffic except to
secure gateways.
C. Route all streams through a secure SD-WAN overlay with traffic inspection at edge routers.
D. Assign static IPs to cameras with MAC address filtering on switch ports.
Answer: B
Explanation: Creating dedicated IoT VLANs with micro-segmentation firewalls blocking outbound traffic
except to secure gateways isolates monitoring devices from core networks, preventing botnet propagation
under HIPAA �164.312(f)(1) and NPRM's network controls for IoT. Mirai variants hit 2024 healthcare
15% more. Micro-segmentation enforces zero-trust per device, surpassing upgrades' scope, and integrates
physical camera mounts. For long-term care, this protects resident ePHI, aligns with audits, and enhances
assessments with traffic logs, mitigating enforcement.
Question: 1132
A healthcare organization wants to balance access to electronic health records with security. Which
technical safeguard aligns with regulatory compliance and facilitates this balance?
A. Assigning generic user accounts to reduce password management
B. Open access for all clinical staff without audits
C. Role-based access control with individualized audit trails
D. Disabling automatic session timeouts to Excellerate workflow
Answer: C
Explanation: Role-based access control ensures only authorized users access data necessary for their role,
while audit trails provide traceability. Open access and generic accounts breach security principles, and
disabling session timeouts increases vulnerability.
Question: 1133
When conducting an environmental risk assessment for a healthcare organization, which element is
MOST critical to evaluate for physical safeguards?
A. Control of facility access using badge and visitor management systems
B. Frequency of employee email usage during working hours
C. Number of software updates installed each month on laptops
D. Scheduling policies for clinical staff rotations
Answer: A
Explanation: Physical safeguards include measures to control physical access to facilities and devices,
with badge and visitor management systems being essential components. Email usage and software
updates relate to technical safeguards and administrative policies, respectively.
Question: 1134
In a scenario where a research institution, acting as a covered entity, receives a subpoena for PHI from a
law enforcement agency investigating a multi-state fraud ring involving business associate pharmacies,
the privacy officer must verify the requester's authorization. Complicating this, the subpoena includes
SUD records under the 2024 Part 2 updates allowing HIPAA-like disclosures with court orders. What
verification process best applies the minimum necessary standard while addressing legal enforcement?
A. Disclose the full patient file upon subpoena validation, as law enforcement overrides minimum
necessary for fraud probes.
B. Require patient authorization before any disclosure, citing Privacy Rule patient rights.
C. Forward the subpoena to the business associate for direct response, avoiding entity involvement.
D. Validate the subpoena's authenticity via the issuing court, limit disclosure to fraud-relevant PHI
excerpts, and document the rationale per minimum necessary policies.
Answer: D
Explanation: HIPAA Privacy Rule � 164.512(f) permits disclosures to law enforcement with valid legal
process like subpoenas, but � 164.502(b) mandates minimum necessary limitations to protect against
over-disclosure. The 2024 Part 2 final rule harmonizes SUD records with HIPAA, permitting court-
ordered disclosures without separate consent but still requiring verification and minimization. In this
fraud scenario, authenticating the subpoena (e.g., via docket checks) and redacting irrelevant PHI (e.g.,
unrelated treatment history) ensures compliance, with documentation supporting audit defense under
OCR enforcement. This balances legal obligations with privacy program administration, unlike blanket
disclosures or unauthorized patient involvement.
Question: 1135
A healthcare organization wants to verify that IT technical safeguards meet HIPAA requirements. Which
process is most effective?
A. Outsource all IT functions to a third party without internal oversight
B. Focus only on physical safeguards and ignore software controls
C. Conduct a comprehensive risk assessment focusing on authentication, encryption, and audit controls
D. Rely only on vendor self-attestation of compliance
Answer: C
Explanation: A comprehensive risk assessment evaluating technical safeguards such as authentication,
encryption, and audit controls ensures compliance with HIPAA security rules. Outsourcing requires
oversight, physical safeguards complement but do not replace IT safeguards, and vendor self-attestation
is insufficient without independent verification.
Question: 1136
A long-term care facility integrates a new RFID tracking system for resident ePHI badges, but the
readers in communal areas are susceptible to signal jamming from unauthorized devices smuggled by
staff. With NPRM proposals for anti-jamming in access controls and 2024 enforcement on monitoring
failures, how should the risk assessment classify this for physical safeguards?
A. Disable RFID during communal hours
B. Low risk, as jamming is rare, and add basic shielding
C. High criticality for jamming enabling badge cloning, deploy encrypted RFID with jamming detection
alerts and staff screening
D. Audit badge usage post-incident only
Answer: C
Explanation: Contingency operations under � 164.310(a)(2)(ii) require procedures for physical access
during emergencies, extending to anti-tampering like jamming. The NPRM proposes detection
mechanisms for physical threats, per rising insider risks. Jamming allows cloning, compromising all ePHI
access. Low classification (B) underestimates; disabling (C) impairs tracking; post-audits (D) miss
prevention. Encrypted RFID with alerts enforces unique identification (� 164.312(a)), screening limits
introduction, and high criticality drives remediation in risk analysis, aligning with OCR's $1M+ fines for
access control lapses.
Question: 1137
A patient requests a copy of their PHI in electronic format. According to HIPAA, which response
complies with their rights?
A. Refuse electronic copies and only provide paper versions to ensure security
B. Provide the PHI promptly in the requested electronic format if readily producible
C. Charge a flat fee regardless of labor or costs involved in producing the copy
D. Deliver the electronic copy only after patient authorization from a notary public
Answer: B
Explanation: HIPAA requires covered entities to provide PHI in the form and format requested by the
patient if readily producible. Refusing electronic copies or requiring notarization beyond standard
authorization is not compliant. Any fees charged must be reasonable and cost-based.
Question: 1138
A clinic's 2026 drone-delivered med kit includes ePHI trackers without encrypted external syncs, risking
interception. Physical handling unverified. What safeguard gap per CPGs, and enforcement?
A. Disposal of devices, recycling.
B. Media safeguards, wipes.
C. Workstation use, geo-fencing.
D. Transmission and physical protections under 45 CFR �164.312(e) and �164.310, enforced via
encrypted syncs and chain-of-custody.
Answer: D
Explanation: CPGs target emerging tech like drones with dual safeguards against interception.
Enforcement demands encrypted protocols, custody verifications, and risk evals to cover innovative
external uses without breaches.
Question: 1139
A patient submits a written request to opt out of all fundraising communications involving their PHI.
What must the healthcare organization do to comply?
A. Cease all future fundraising communications involving that patient�s PHI
B. Continue fundraising communications but without PHI references
C. Obtain patient�s authorization before further fundraising communications
D. Inform the patient that fundraising communications are exempt from opt-outs
Answer: A
Explanation: HIPAA requires covered entities to honor opt-out requests for fundraising communications
promptly and refrain from sending further communications that include PHI to that individual.
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Latest 2026 Updated AHIMA-CHPS Real test Questions

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