Termination Procedures: Closing access the day someone leaves

45 CFR 164.308(a)(3)(ii)(C) covers termination procedures. In most assessments the control itself is present and the record proving it is not, which is why this requirement produces findings at organizations that are, in practice, doing the work.

What the rule says

Termination procedures (Addressable). Implement procedures for terminating access to electronic protected health information when the employment of, or other arrangement with, a workforce member ends or as required by determinations made as specified in paragraph (a)(3)(ii)(B) of this section.

That is the text of 45 CFR 164.308(a)(3)(ii)(C). Read it closely: it describes an outcome to achieve, not a product to buy, which is why two practices of the same size can satisfy it in different ways and both be right.

This is an addressable implementation specification, and addressable does not mean optional. Under 45 CFR 164.306(d)(3) you assess whether the specification is reasonable and appropriate in your environment, and then either implement it or, if implementing it is not reasonable and appropriate, document why and implement an equivalent alternative measure if that is reasonable and appropriate. The documented reasoning is itself part of the requirement, so an undocumented decision to skip it is the finding.

What this looks like in practice

In an assessment, 45 CFR 164.308(a)(3)(ii)(C) is not one question. It resolves into several, and each one is really asking for different evidence. These are among the questions asked about it:

• Does the organization have a procedure and checklist to revoke logical access and recover access devices and equipment when a workforce member's role ends?
• Is there a formal process for human resources to notify those responsible for access management of terminations, departures, or other changes requiring access revocation?
• Does the organization ensure that workforce members and other parties return organizational assets in their possession upon termination or change of their engagement?

Ownership usually sits with the security official, though the evidence is often produced by someone else, which is where the trail breaks. A control that works but has no owner tends to stop working the month the person who quietly maintained it changes roles.

Who this applies to

Every covered entity and every business associate, at any size. 45 CFR 164.306(b) allows flexibility of approach, so a two-provider practice and a hospital system may implement this differently and both comply. What flexibility does not allow is skipping the decision: the smaller the organization, the more the written reasoning carries the weight, because there is no scale of operation to make the control self-evident.

Building it, in order

These steps are one way to meet it, drawn from our question bank. Unless a step names a provision, the Security Rule does not require that particular measure: 45 CFR 164.306(b)(1) lets you use any security measures that allow you to reasonably and appropriately implement the standards and implementation specifications, chosen with the factors in 45 CFR 164.306(b)(2).

The sequence below is the order that produces evidence as a by-product rather than as a separate documentation exercise:

1. Establish a termination procedure with a checklist for revoking access and recovering assets.
2. Disable all logon accounts and access rights upon separation or role change.
3. Recover access-control devices such as ID badges, keys, and key-cards.
4. Recover issued computers, mobile devices, and any organizational data in the worker's possession.
5. Document a process by which human resources notifies access administrators of terminations, role changes, and departures.
6. Define the timeframe for notification so access can be revoked promptly.

Where else this maps

The questions behind 45 CFR 164.308(a)(3)(ii)(C) also map to HHS 405(d) HICP (2023 Edition) CSP 10, CSP 3 and NIST SP 800-66 Rev. 2 5.1.3, 5.3.1, 5.5.1, which are voluntary guidance rather than law; following them does not by itself establish compliance with any law. That matters for scoping: the same evidence can be written once and referenced from each, rather than rewritten per framework.

Evidence an assessor asks for

For this requirement the evidence types that satisfy it are policy, procedure, and record. The distinction matters more than it looks: a policy states what you intend to do, a procedure states how, and a record proves it happened on a date. Auditors ask for all three, and a practice that has written the first two often has nothing for the third.

Date every document and keep the superseded versions. 45 CFR 164.316(b)(2)(i) requires the documentation 164.316(b)(1) calls for (the Security Rule policies and procedures, and the written record of any action, activity or assessment the Security Rule requires to be documented) to be retained for six years from the date of its creation or the date when it last was in effect, whichever is later, so a policy you replaced two years ago is still part of the record.

Where this usually goes wrong

The most common failure here is treating addressable as optional. A practice decides the specification does not fit, implements nothing, and writes nothing down. At assessment the answer to "why not" is a verbal explanation, which is not evidence. The second most common failure is the opposite: implementing an alternative that works, and still not recording the reasoning, so the control looks accidental.

What to do about it

• Produce the evidence, not the intention. For 45 CFR 164.308(a)(3)(ii)(C) that means a signed, dated policy with a named owner and a review date, a step-by-step procedure someone unfamiliar with the task could follow, and dated records of each occurrence, not a description of the process. If the only evidence is that someone knows how this works, you have a practice and not a record.
• Put a name on it. Your security official should be recorded as the owner. A control with no owner stops working the month the person who quietly maintained it changes roles, and nobody notices.
• Review it on a fixed date, not when you remember. In our question bank this is weighted Critical: a gap here is raised as a critical finding (a partial answer as high). Put the review on the calendar with an owner, and keep the dated output of each one.
• If you decide not to implement it, write the decision down. Addressable is not optional: under 45 CFR 164.306(d)(3) the documented assessment IS part of the requirement, so an undocumented decision to skip it is the finding, and a working alternative with no recorded reasoning looks accidental.

If 45 CFR 164.308(a)(3)(ii)(C) is new to you, the useful first step is not a policy template. It is writing down what you already do, dating it, and naming an owner. That turns an undocumented practice into evidence, and it usually reveals the real gap.

Related requirements

• Workforce Clearance Procedure: Workforce clearance that fits a small practice
• Information Access Management: Role-based access that maps to real job functions
• Authorization and/or Supervision: Authorization and supervision for staff who touch ePHI

References

• 45 CFR 164.308(a)(3)(ii)(C), in 45 CFR 164.308 on eCFR. Quoted text verified against the eCFR text current as of 2026-10-06.
• The Required and Addressable designations are defined at 45 CFR 164.306(d).
• Crosswalk references in this post are the mappings in our question bank, and are not verified against the published text of those standards.
• This post describes what a requirement asks for and what evidence documents it. It is not legal advice, and your counsel owns the conclusion. State law may impose additional obligations; HIPAA preempts a State law only where it is contrary to HIPAA (45 CFR 160.202, 160.203).