hipaa audit checklist pdf

For additional resources concerning ComplyAssistant’s HIPAA Facility Walkthrough Checklist is one of the free tools we offer to our website visitors to assist in their compliance needs. trailer Audit Controls: Audit your ePHI to record and analyze activity in case of a data breach. Organize security documents. The HIPAA Coordinator has been appointed. Official HIPAA Security Compliance Audit checklist document was released by the Department of Health and Human Services' (DHHS) Office of e-Health Standards. 0000016828 00000 n 0000015259 00000 n Risk Management Implementation Specification . Toolkit(Tools, Best Practices & Checklist) Goal: To make compliance an enjoyable and painless experience . This checklist is not a comprehensive guide to compliance with the rule itself*, but rather a practical approach to help healthcare businesses make meaningful progress toward building a better understanding of HIPAA HIPAA-Security-Checklist-HH.docx Kim C. Stanger Phone (208) 383-3913 kcstanger@hollandhart.com www.hollandhart.com 164.310(d)(1) Device and media controls: Implement policies and procedures that govern the receipt and removal of hardware and electronic media that contain EPHI into and out of a facility, and the movement of these items within the facility. The HIPAA Security Rule establishes very clearly the requirements for the Risk Management implementation specification, the Audit Controls standard, and the Evaluation standard: Risk Management Implementation Specification. Disclaimer: Performing the following checklist does not guarantee that your organization is compliant with the HIPAA Audit protocol or OCR regulations. As healthcare documentation and billing have become more systematic, federal laws have been enhanced to further modernize the flow of health information and … hipaa security checklist NOTE: The following summarizes HIPAA Security Rule requirements that should be implemented by covered entities and business associates and addressed in applicable policies. Here is a HIPAA Compliance Checklist to … This is because no two Covered Entities (CEs) or Business Associates (BAs) are identical. Introduction to the HIPAA Security Rule Compliance Checklist. HIPAA Compliance Checklist Most healthcare practices and business associates still don't accurately and regularly manage a true HIPAA program. This checklist is composed of general questions about the measures your organization should have in place to ensure HIPAA compliance, and does not qualify as legal advice. PDF; Size: 158.6 KB. This is 2 page document of Sample - Interview and Document Request for HIPAA Security Onsite Investigations and Compliance Audit Reviews. 618 TDO KB October 21, 2020 HIPAA 0 3394. Attempting to manage your compliance program manually and without the help of expert healthcare security consultants will not only take up massive amounts of time, it could result in your … A HIPAA audit checklist is the ideal tool to identify any risks or vulnerabilities in your healthcare organization or associated business. Need additional help? 0000001300 00000 n HIPAA rules are designed to ensure that any entity that collects, maintains, or uses confidential patient information handles it appropriately. 0000030994 00000 n Remediation is an important item on an audit checklist for HIPAA. If a wireless system is used, it is business class and encrypted. A HIPAA compliance checklist is a tool that helps institutions and their associates who handle Protected Health Information (PHI) stay compliant with the Health Insurance Portability and Accountability Act (HIPAA). 711 0 obj <>stream Determine the person who will be in charge of privacy & security. SCTG’s annual SOC 2 Type II audit serves as the foundation for helping our healthcare customers meet their HIPAA … endstream endobj 250 0 obj <>/Filter/FlateDecode/Index[9 194]/Length 29/Size 203/Type/XRef/W[1 1 1]>>stream 0000001567 00000 n Click Here! The HIPAA Audit Protocol Checklist is an Excel document that consists of a chart with the information that HHS will look for when they conduct an audit. It is not to be construed as legal advice. How to save a pdf into TDO. Unfortunately, no formalised version of such a tool exists. It may be time-consuming to work your way through this free HIPAA self-audit checklist. The aim of a HIPAA audit checklist would be to find any possible risks to the integrity of electronically … They can help you make sure your HIPAA compliance program is in good shape. 0000032616 00000 n ... (audit logs/access logs/security incident reports)? There are steps you can take to prepare for HIPAA compliance audit. HHS, OCR, DOJ and SAG: 2. created the following checklist. However, it is essential that you cover every single aspect of it. Create a risk management plan & risk analysis. This does not take the place of a Risk Assessment and should not be considered legal advice. „,kW20t#I1œ–Ñðjíi sÒÒ2ÀŽ:$ ÅÒ|ìÂÕ +CX¼“žH4¶ View HIPAA Audit Checklist released by DHHS. 0000008265 00000 n Covered entities and business associates should ensure that they have required policies in place to minimize or avoid penalties under To ensure the safety and privacy of personal medical data and protected health information, the United States government passed the Health Insurance Portability and Accountability Act of 1996. They have taken this information from HHS and have put it into an easy-to-use and organized format, where you can filter, search, and adjust the list as necessary. Think from the perspective of the government (or a third-party auditor). Assessment: 4. Sample HIPAA Security Rule Checklist Template. To download PDF: Official DHHS released HIPAA Audit Checklist. 251 0 obj <>stream This article is part of a series of posts relating to HIPAA law and regulation. Then, go over the steps you can take to meet the demands of an audit and ensure compliance with HIPAA regulations. 0000014173 00000 n For legal guidance as to the application of the HIPAA and HITECH acts to specific situations, consult an attorney with expertise in the field. 0000023241 00000 n 0000047379 00000 n State-of-the-art technological tools are integral to remediation procedures. CE’s need to provide a complete audit trail of the data breach and what PHI be able to show the OCR exactly how a data breach occurred with a complete audit trail and reporting. 855-85-HIPAA or info@compliancygroup.com This checklist is composed of general questions about the measures your organization should have in place to state that you are HIPAA compliant, and does not qualify as legal advice. The American Recovery and Reinvestment Act of 2009 … Page 1 of 4 HIPAA AUDIT CHECKLIST Checklist Category Document Name/Description Received Y/N Document/File Name(s) General Information General Information Complete the enclosed “HIPAA Limit your review. %%EOF Dive into the details given here and make a complete use of it. 0000023146 00000 n The structure of a HIPAA release depends on the condition of the patients. It should contain all aspects of HIPAA Rules that could potentially be assessed by OCR during its ‘desk audits’ and full compliance audits that will follow. The 10-Point HIPAA Audit Checklist. Explain how employees are trained and how you track their completion: 8. HIPAA compliance is all about adopting good processes in your organization, and HHS has laid out a path to compliance that is nearly a checklist. 0 203 49 %PDF-1.3 %âãÏÓ Speaking of the HIPAA compliance audit checklist, they may include technical infrastructure, hardware and software security capabilities. Limit your review. Risk Analysis: 4 . Emergency Access Procedure - establish and implement as … Integrity: To be HIPAA compliant, CEs needs to be able to prove that the ePHI they manage is protected from threats both … An important provision of the HIPAA Omnibus rule, which went into effect in March 2013, states that business associates of the primary data handlers, as well as subcontractors of these BAs, also must be HIPAA compliant. The HIPAA Security Rule establishes very clearly the requirements for the Risk Management implementation specification, the Audit Controls standard and the Evaluation standard. FREE 10+ HIPAA Security Checklist Templates in PDF | MS Word HIPAA checklist sets the quality for safeguarding sensitive patient knowledge. HIPAA Compliance Checklist for 2020 By: Neeraj Annachhatre | 3/5/2020 HIPAA was adopted in 1996 and since then, Covered Entities (CEs) have been required to protect individuals’ personal health information or face hefty fines for non-compliance. HIPAA Audits: A Nine Step Checklist Here are nine tips to help you prepare now in case your dental practice is chosen for a HIPAA audit. Integrity It may be time-consuming to work your way through this free HIPAA self-audit checklist. 0000041957 00000 n True, not every dental practice will get audited, but if your practice is covered by HIPAA you should take these steps anyway. This standard has no implementation specifications, so let’s jump right to the key question: What will be the audit control capabilities of the information systems with EPHI? 0000028253 00000 n Complying with the HIPAA Security Rule is a complex undertaking because the rule itself has multiple elements. ˆ°¤+³2 0000028650 00000 n 0000053935 00000 n Must have document for all HIPAA Security Audit preparations. Administrative safeguards should be in place to establish policies and procedures that employees can reference and follow to ensure that they’re maintaining compliance. Audit Controls: Audit your ePHI to record and analyze activity in case of a data breach. While there is some irony in providing a compliance checklist when we often hear ‘compliance is much more than checking a box,’ there are program elements that can – and should – be checked off. CE’s need to provide a complete audit trail of the data breach and what PHI be able to show the OCR exactly how a data breach occurred with a complete audit trail and reporting. <]/Prev 454435/XRefStm 1567>> Go beyond policy. Proven. The audits performed assess entity compliance with selected requirements and may vary based on the type of covered entity or business associate selected for review. HIPAA rules are designed to ensure that any entity that collects, maintains, or uses confidential patient information handles it appropriately. Auditors rely on HHS directives to ensure that an organization has adequate resources in place to remedy potential security breaches. The 10-Point HIPAA Audit Checklist. 0000005089 00000 n The OCR’s standard audit protocol requirement has 168 performance criteria – 78 for security, 81 for privacy, and 10 for breach – all of which are essential to ensure compliance with HIPAA. Details.File Format. Convert the file to a PDF and then password-protect the PDF. A HIPAA compliance checklist is a tool every HIPAA-Covered Entity and Business Associate should use as part of their compliance efforts. Be ready to talk security. The HIPAA Security Rule establishes very clearly the requirements for the Risk Management implementation specification, the Audit Controls standard and the Evaluation standard. hÞb```b``çe`’® ÀÀ For this reason, we created a simple HIPAA Security Rule compliance checklist to quickly determine whether or not your office is on the right track. 0000003722 00000 n Server data is encrypted. Maintaining adherence to HIPAA is no small feat considering the dozens of criteria that are considered in the HIPAA Audit Checklist. 0000028226 00000 n Remediation is an important item on an audit checklist for HIPAA. As a best practice, seek assistance from a certified HIPAA Auditor when completing a Security Risk Analysis. Audit yourself. Achieving and maintaining HIPAA compliance requires both thoughtful security and ongoing initiative. Organize security documents. We’ll look at the compliance rules and HIPAA auditing protocols. 0000031983 00000 n HIPAA Policies and Procedures within the last year? Must have document for all HIPAA Security Audit … Where applicable, rule numbering and language has been preserved. Successfully completing this checklist does not certify that you or your organization are HIPAA … 0000027662 00000 n %PDF-1.6 %���� HIPAA Security Rule Reference Safeguard (R) = Required, … The email system is secure and encrypted. This involves the employment of security measures that … 0000019833 00000 n Need help completing your Checklist? To download PDF: Official DHHS released HIPAA Audit Checklist. 0000001746 00000 n The Transaction Compliance Officer has been appointed. 0000006957 00000 n 203 0 obj <> endobj Instructions: Review the list of 12 fundamental HIPAA Security Rule compliance requirements and check only those items that you actively manage. Be ready to talk security. The HIPAA Security Rule Checklist: Administrative Safeguards . Have you conducted the following Audits/Assessments? 0000003610 00000 n HIPAA Audit Protocol Checklist When it comes to HIPAA audits, protocol must be followed in order to ensure that your health care business or practice is prepared to respond to a request from the Department of Health and Human Services (HHS) Office for Civil Rights (OCR). 0000004629 00000 n You don’t have to do anything ahead of time; If HHS investigates your practice, then this rule becomes relevant to you, but there’s nothing here that you need to do proactively. HIPAA can be overwhelming. Audit yourself. Implement security measures sufficient to reduce … Work with Vector Choice to make sure you have everything in place. not knowing “What is HIPAA compliance?” – is not accepted as a justifiable argument for failing to comply with HIPAA. Our goal is to institute a “culture of compliance” in each of our client organizations and the use of a properly outlined HIPAA Facility Walkthrough Checklist is a very important in a … Webinar Objective Understand OCR/HHS HIPAA/HITECH audit program and steps required to prepare for an audit 3 . hÞbbbf`b``Ń3Î úc€ hè 0000023076 00000 n You should always consult a HIPAA … the HIPAA regulations. 0000047030 00000 n The HIPAA Checklist. 0000041689 00000 n All you have to do is follow it. 3. You may submit feedback about the audit protocol to OCR at HIPAA is United States federal legislation covering the data privacy and security of medical information. Individuals and organizations who fail the HIPAA audit are usually given time to correct their failings unless it is found they have “willfully neglected” to comply with HIPAA – in which case a substantial financial penalty can be issued. Generally, during an audit, officials will analyze the controls, processes, and policies of hospitals in accordance with the HITECH Act. The citations are to 45 CFR Part 164. HHS, OCR, DOJ and SAG: ... CoveredEntityCharts.pdf 12 . If you need a detailed frame of a HIPAA security rule checklist, this template … #6: Learn How to Handle Information Breaches. Toolkit(Tools, Best Practices & Checklist) Goal: To make compliance an enjoyable and painless experience . Disclaimer: This checklist is not meant to be a complete or formal list guaranteeing HIPAA compliance. AUDIT TIP: If audited, you must provide all documentation in an eligible format to auditors. Please check off as applicable to self-evaluate your practice or organization. Go beyond policy. 0000005634 00000 n To actively manage a HIPAA requirement, you must keep the information up-to-date and/or perform the task at least once per year (annual requirements are indicated by an asterisk*). 0000018591 00000 n 0000014026 00000 n H‰\ÑÉnƒ0ໟbŽÉ!bIœEBH M%]TÒ ö"cràí;ÃD©TKàÏ2?ã¨(ŸK׎}„ÞT8BÓ:pèoÁ \ðÚ:•¤`[3ÞWóÝtµWWÓ0bWº¦WYÑ'mc˜`ñdû.Uô,†Ö]añUTKˆª›÷?Ø¡!†‹ ½èµöou‡Íe«ÒÒ~;N+ªù{â. 0000002893 00000 n 0000004164 00000 n W ith ClinicSource, any patient records, including evaluations, can be securely emailed directly from the software. It provides a practical overview of the various office procedures that should be reviewed to ensure compliance with HIPAA. This individual answers to the Practice Executive and oversees the efforts of other team members. State-of-the-art technological tools are integral to remediation procedures. Business class HIPAA compliant firewalls are installed and functioning properly. 0000002072 00000 n h��Z�r۸���ә:� �f2�Xr�i|[�4�h:�I�P��o���}��V���w ��)��z@���ppp�D�3�p|f:.��l��d�a�̳��a��VX�4|��4}�@��c�m[�@��; �#��3�^t,"����C���iC*`�I$�Fǵ��9d�KL!� � f&��� ��X������\̊��\a�f 0000015555 00000 n To download PDF: Official DHHS released HIPAA Audit Checklist. 164.312(b) Have you implemented Audit Controls, hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI? HIPAA COMPLIANCE AUDIT CHECKLIST Y | N. CompliancTrPartners.c 888.388.47 2079 aringn ad Suie aringn ills Complianc Tr Partners SECURITY Technical Safeguards There are access control policies and procedures, which include: Unique User Identification - assign a unique name and/or number for identifying Open Enrollment Compliance Checklist 2 To help you prepare for open enrollment season, HUB International presents the following questions to assist with your compliance obligations. This one, based on the one created by AdviseTech6 and elaborated with the expertise of HIPAA engineers at Atlantic.Net 7 , provides an overview of core concerns when setting up servers for a compliant healthcare environment: HIPAA is a US law that requires the careful handling of PHI or individually identifiable health information. 0000031350 00000 n Think from the perspective of the government (or a third-party auditor). * AUDIT TIP: If audited, you must provide all documentation for the past six (6) years to auditors. However, it is essential that you cover every single aspect of it. Auditors rely on HHS directives to ensure that an organization has adequate resources in place to remedy potential security breaches. 3 • OCR audits “primarily a compliance improvement activity” designed to help OCR: better understand compliance efforts with particular aspects of the HIPAA Rules determine what types of technical assistance OCR should develop develop tools and guidance to assist the industry in compliance self-evaluation and in preventing breaches G°7d0œcý#pѼí„П“\\\V&X10°ž˜p!È)Ž%G¨ãjÃG¯|3à–030ܒa {ƒç\”ƒí f"a€ ‹ð(8 The purpose of this checklist is to present HIPAA’s dense, and oftentimes, confusing requirements in more accessible language. Then, use the checklist for HIPAA policy & procedures on privacy and security to see what is missing. Gather employee training manuals. Is your HIPAA Compliance Plan completed and stored in a location where all staff members can find it? 0000002557 00000 n 0000003414 00000 n Download. User Access Controls (UAC) have been turned on and are operating correctly. 0000014849 00000 n Glossary 1. HIPAA COMPLIANCE AUDIT CHECKLIST Y | N. CompliancTrPartners.c 888.388.47 2079 aringn ad Suie aringn ills Complianc Tr Partners SECURITY Technical Safeguards There are access control policies and procedures, which include: Unique User Identification - assign a unique name and/or number for identifying and tracking user identity. View HIPAA Audit Checklist released by DHHS. Helping Referring Doctors Reset their Password. Successfully completing this checklist does not guarantee that you or your organization are HIPAA compliant. a DOL audit Checklist: Open Enrollment Compliance Let’s prepare for a compliant and stress-free enrollment season. Covered Entity: 3. ☑ HIPAA Checklist: How to Comply with Rule 5. 0000009942 00000 n Review your business … HIPAA Compliance Checklist The following questions represent the core components necessary for HIPAA compliance. Ignorance of HIPAA – i.e. Webinar Objective Understand OCR/HHS HIPAA/HITECH audit program and steps required to prepare for an audit 3 . This is 2 page document of Sample - Interview and Document Request for HIPAA Security Onsite Investigations and Compliance Audit Reviews. This person serves as the primary expert on all areas of electronic data transaction and reports to the HIPAA Coordinator. startxref �h.�c�Ј��|�:&�M#@�Yh3?���8,0�� t�Ј`�mӈ���z�߄��]���"n���(ϖa�l��H_���9��������k�s���^Z��ϓpQ4V�y�}��� �� ��"*�Oi��V��a�z�"���oeH^3���'m������`�֋-�/���k(g��9��?���{ � ��S0F�>��s�-Ʈ��1H[�݃���hXl�G���ljDdZB�E}�/��"nz�]#�Z_�8���7Y}sP#� j�I��_j/�ڠƶ�bP7���=1�1}��7��9��Q� �p��0��B=��[\n^^l�Ï�G�}�I2a�i x�zL9c�Cs� �w�f�y��. A HIPAA audit checklist should be based on HIPAA requirements and the HHS Audit protocol. 0000003836 00000 n ... HIPAA Audit Checklist. This compliance checklist was created using data from the HHS HIPAA Security Series to ensure consistency across all requirements. HIPAA SECURITY CHECKLIST www.eset.com Things to know before you start a compliance initiative FOR HEALTHCARE * This information is intended to serve as a general resource and guide. Since its adoption, the rule has been used to manage patients’ confidentiality alongside changing technology. The audit protocol is organized by Rule and regulatory provision and addresses separately the elements of privacy, security, and breach notification. If you are not sure which training is needed for employees, use our guide on how to select HIPAA training for employees. 0000014616 00000 n 0000011453 00000 n The HIPAA Security Rule outlines specific regulations that are meant to prevent breaches in the creation, sharing, storage, and disposal of ePHI. If you are looking for a HIPAA security audit policy then you are definitely on the right track. 0000004545 00000 n For additional resources concerning The citations are to 45 CFR Part 164. The audit protocol is organized by Rule and regulatory provision and addresses separately the elements of privacy, security, and breach notification. Need help completing your Checklist? Provide Date HIPAA Compliance Plan was enacted and where it is located: 9. The network is scanned for ports that should be blocked. Additional policies are required by the HIPAA Security Rule. Official HIPAA Security Compliance Audit checklist document was released by the Department of Health and Human Services' (DHHS) Office of e-Health Standards. Findings: 5. Use our Free HIPAA compliance audit checklist to see if you are complaint. Following each item on the checklist does not guarantee you will be HIPAA … 0000027967 00000 n Trusted. *AUDIT TIP: If audited, you must provide all documentation for the past six (6) years to auditors. (R) 164.312(c)(1) Integrity: Implement policies and procedures to protect ePHI from improper alteration or destruction. ASPS RECOMMENDED HIPAA COMPLIANCE CHECKLIST Medical records have always included some of the most intimate details of a person's life; however, federal laws regulating the privacy of that information were nonexistent until 1996. Maintaining adherence to HIPAA is no small feat considering the dozens of criteria that are considered in the HIPAA Audit Checklist. It is in your best interests to compile a HIPAA audit checklist and conduct an audit on your own precautions for protecting the integrity of ePHI. 3 • OCR audits “primarily a compliance improvement activity” designed to help OCR: better understand compliance efforts with particular aspects of the HIPAA Rules determine what types of technical assistance OCR should develop develop tools and guidance to assist the industry in compliance self-evaluation and in preventing … Investigations and Compliance Audit Reviews. By reviewing and updating your HIPAA compliance checklist frequently, you will be able to review the audit protocol, find any matching measures on the checklist still awaiting implementation, and prioritize them in case your organization is randomly selected for an audit. Any entity that deals with protected health info should make sure that all the desired physical, network, and method security measures are in the organized situation. Here are nine tips to help you prepare now in case your dental practice is chosen for a HIPAA audit. In March 2013, the enactment of amendments to the Health Insurance Portability and Accountability Act (HIPAA) made it important for healthcare organizations and other covered bodies to complete a HIPAA audit checklist. Glossary 1. promo.mgis.com. The HIPAA Compliance Checklist: The Security Rule. Gather employee training manuals. 0000046772 00000 n 2.2 – Assigned Security Responsibility. The policy which is given here includes all the necessary components like rationale, purpose, scope, definitions, administrative rules, audit responsibilities and much more. xref Download the PDF. endstream endobj 204 0 obj <>/Metadata 6 0 R/OutputIntents[<>]/Pages 5 0 R/StructTreeRoot 9 0 R/Type/Catalog/ViewerPreferences<>>> endobj 205 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/Properties<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 206 0 obj <> endobj 207 0 obj <> endobj 208 0 obj [/Separation/PANTONE#20185#20C/DeviceCMYK<>] endobj 209 0 obj <> endobj 210 0 obj <> endobj 211 0 obj <> endobj 212 0 obj <>stream Also, we prepared a complete checklist for HIPAA Compliance. 0000032293 00000 n HIPAA audit requirements can cover a 0000000016 00000 n You can refer to it as your guidance. Checklist for HIPAA-compliant IT infrastructure & related needs The step-by-step needs for infrastructural compliance can be organized within a HIPAA compliance checklist. Create a risk management plan & risk analysis. 0000012761 00000 n The audits performed assess entity compliance with selected requirements and may vary based on the type of covered entity or business associate selected for review. Privacy and Security of medical information both thoughtful Security and ongoing initiative HIPAA/HITECH audit and... Version of such a tool every HIPAA-Covered Entity and business Associate should use as part of their needs... 2 page document of Sample - Interview and document Request for HIPAA US. Controls: audit your ePHI to record and analyze activity in case your dental will. Tool every HIPAA-Covered Entity and business Associate should use as part of their compliance needs ensure that maintaining... It is essential that you cover every single aspect of it are required by the HIPAA Security audit policy you. For HIPAA-compliant it infrastructure & related needs the step-by-step needs for infrastructural compliance can be emailed... Item on an audit and ensure compliance with HIPAA regulations not accepted as a best practice, assistance! On HIPAA requirements and check only those items that you or your organization are HIPAA … HIPAA. Safeguard ( R ) 164.312 ( c ) ( 1 ) integrity: Implement policies and procedures should! Use of it to identify any risks or vulnerabilities in your healthcare organization or business! Been used to manage patients’ confidentiality alongside changing technology of the various office procedures that be... Policy then you are complaint complete or formal list guaranteeing HIPAA compliance checklist created... The list of 12 fundamental HIPAA Security Rule establishes very clearly the requirements for the past six ( 6 years. Let’S prepare for an audit 3 successfully completing this checklist does not take the place a! Your ePHI to record and analyze activity in case of a Risk and. The past six ( 6 ) years to auditors of this checklist is to present HIPAA’s dense, and notification.: 8 is no small feat considering the dozens of criteria that are considered in the HIPAA Rule. Policy then you are complaint audit Controls: audit your ePHI to record analyze!: to make compliance an enjoyable and painless experience United States federal legislation covering the data privacy and of! Objective Understand OCR/HHS HIPAA/HITECH audit program and steps required to prepare for HIPAA policy & procedures privacy! A DOL audit checklist, you must provide all documentation for the Risk Management specification! Meet the demands of an audit 3 to help you prepare now in of. Need a detailed frame of a HIPAA release depends on the condition of the government ( a... 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