insights on secure & simple e-signatures

Electronic signatures are now standard in healthcare. From patient intake forms and consent documents to treatment authorizations and business agreements, eSignatures help providers move faster and reduce paperwork.

But when those signatures involve protected health information (PHI), the stakes are higher. Not all electronic signature solutions are HIPAA compliant. Using the wrong one can expose your organization to serious compliance and security risks.

In this guide, we’ll break down what makes an electronic signature HIPAA compliant, the specific safeguards required, common mistakes healthcare organizations make, and how to safely implement electronic signatures without putting PHI at risk.

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What Does “HIPAA Compliant Electronic Signature” Really Mean?

HIPAA does not prohibit electronic signatures. In fact, HIPAA is largely technology-neutral. It does not define or mandate a specific signing method.

Instead, HIPAA focuses on how electronic protected health information (ePHI) is created, transmitted, stored, and accessed during the signing process.

An electronic signature is considered HIPAA compliant only if the system handling it meets HIPAA’s required safeguards for protecting PHI.

It’s also important to separate HIPAA from other laws:

• ESIGN Act & UETA: Establish the legal validity of electronic signatures
• HIPAA: Governs the security and privacy of PHI involved in the process

An eSignature can be legally valid but still non-compliant with HIPAA if PHI is mishandled.

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HIPAA Requirements That Apply to Electronic Signatures

HIPAA compliance for electronic signatures falls under the HIPAA Security Rule, which defines three safeguard categories.

1. Administrative Safeguards

These are policies and procedures that control how PHI is handled.

For eSignatures, this includes:

• Defined access roles for staff
• Workforce training on PHI handling
• Vendor risk management
• Documented incident response procedures

If your signing provider has access to PHI, you must also have a Business Associate Agreement (BAA) in place (more on that below).

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2. Technical Safeguards

This is where many eSignature tools fall short.

HIPAA requires:

• Access controls to ensure only authorized users can view or sign documents
• Audit controls to track who accessed PHI and when
• Integrity controls to prevent unauthorized document changes
• Transmission security to protect PHI in transit

Email-based workflows and consumer file-sharing tools often fail here.

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3. Physical Safeguards

Even cloud-based systems must account for physical security.

This includes:

• Secure data centers
• Controlled access to servers
• Protections against unauthorized physical access to stored PHI

Reputable HIPAA-focused platforms use hardened, audited infrastructure to meet these requirements.

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Required Security Features for HIPAA-Compliant eSignatures

A HIPAA-compliant electronic signature platform should include all of the following:

Encryption (In Transit and At Rest)

PHI must be encrypted:

• In transit (TLS/HTTPS when documents are sent or accessed)
• At rest (encrypted storage on servers)

If your provider cannot clearly explain their encryption standards, that’s a red flag.

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Strong Authentication & Access Controls

HIPAA requires limiting access to authorized individuals.

Look for:

• Secure signer authentication
• Role-based access for staff
• Multi-factor authentication
• Time-limited or access-controlled signing links

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Tamper-Evident Audit Trails

HIPAA requires the ability to audit activity involving PHI.

A compliant eSignature system should automatically record:

• Who viewed the document
• Who signed
• Date and time stamps
• IP addresses or access context
• Any document changes

This audit trail must be immutable and securely stored.

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Data Retention & Secure Storage

Signed documents containing PHI must be:

• Stored securely
• Protected from unauthorized access
• Retained according to your policies
• Deleted securely when no longer needed

Storing signed PDFs in unsecured cloud drives or email inboxes is a common compliance failure.

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Minimal PHI Exposure

HIPAA emphasizes minimizing unnecessary PHI access.

Best-practice eSignature platforms:

• Limit document visibility to only required parties
• Avoid exposing PHI in email notifications
• Keep PHI contained within a secure signing environment

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Business Associate Agreements (BAAs): A Non-Negotiable Requirement

If an eSignature vendor creates, receives, maintains, or transmits PHI on your behalf, they are considered a Business Associate under HIPAA.

That means:

• A signed BAA is required
• No BAA = no HIPAA compliance

Many popular consumer eSignature and file-sharing tools either:

• Refuse to sign BAAs
• Restrict BAAs to enterprise tiers
• Exclude key features from BAA coverage

Always confirm that:

• A BAA is available
• It clearly covers electronic signatures and document storage
• It applies to all environments where PHI is processed

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Common HIPAA Mistakes with Electronic Signatures

Healthcare organizations often assume they’re compliant when they’re not. Here are the most common pitfalls:

Using Consumer eSignature Tools

Many general-purpose eSignature platforms are designed for sales contracts—not PHI.

Common issues:

• No BAA
• Insecure email notifications
• Weak access controls
• Limited audit logging

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Emailing Documents for Signature

Email is not inherently HIPAA compliant.

Problems include:

• PHI visible in inbox previews
• Forwarding risk
• Lack of access controls
• No audit trail

Email should never be the primary method for collecting signed healthcare documents.

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Storing Signed Documents Insecurely

Even if the signing step is secure, compliance can fail afterward.

Risky practices:

• Saving signed PDFs to local desktops
• Uploading to consumer cloud storage
• Keeping PHI indefinitely with no retention policy
• Lack of an audit trail of those accessing ePHI

HIPAA applies to the entire document lifecycle, not just the signature.

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Email can be used in healthcare workflows—but only when specific safeguards are in place. If your organization must use email to send or receive PHI, follow these steps to reduce HIPAA risk.

1. Use an Email Service That Supports HIPAA Compliance

Not all email platforms are HIPAA compliant by default. Choose a provider that:

• Supports encryption in transit and at rest
• Offers access controls and administrative logging
• Will sign a Business Associate Agreement (BAA)

Without a BAA, email should never be used to transmit PHI.

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2. Enable Encryption for All PHI-Related Messages

Encryption is a core HIPAA technical safeguard.

• Use TLS encryption for messages in transit
• Apply end-to-end or portal-based encryption when possible
• Avoid sending PHI in plain-text email bodies or attachments

If encryption cannot be enforced, PHI should not be emailed.

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3. Avoid Including PHI in the Email Body

Emails are easily forwarded, previewed, or accessed by unauthorized users.

Best practice:

• Keep emails notification-only
• Do not include diagnoses, treatment details, or identifiers in the message
• Use secure links that require authentication to view content

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4. Control Access to PHI After Delivery

HIPAA applies after the email is received.

• Restrict inbox access to authorized staff
• Avoid shared inboxes without role-based controls
• Prohibit downloading PHI to local desktops or personal devices

PHI should remain in controlled systems—not personal storage.

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5. Maintain Audit Trails and Logging

HIPAA requires the ability to track PHI access.

• Log who sends and receives PHI-related emails
• Monitor access to linked documents or portals
• Retain logs according to your compliance policies

If you can’t audit it, you can’t defend it.

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6. Obtain Patient Consent for Email Communication

If patients request email communication:

• Inform them of the risks
• Document their consent
• Limit email use to the minimum necessary

Patient preference does not remove your obligation to safeguard PHI.

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7. Train Staff on Secure Email Practices

Human error is one of the biggest HIPAA risks.

• Train staff on when email is allowed
• Enforce verification of recipient addresses
• Establish procedures for misdirected emails
• Document training for compliance audits

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8. Use Secure Alternatives Whenever Possible

Email should not be the default for handling PHI.

Whenever feasible, use:

• Secure portals
• HIPAA-compliant electronic signature platforms
• Encrypted form and document workflows

These tools dramatically reduce exposure compared to email.

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Bottom Line

Email can be made more compliant, but it is rarely the best option for handling PHI. For collecting signatures, forms, and sensitive documents, secure HIPAA-compliant workflow platforms are safer, easier to audit, and far less risky than relying on email alone.