Information Security Policy

This Policy document encompasses all aspects of security surrounding confidential company information and must be distributed to all company employees. All company employees must read this document in its entirety and sign the form confirming they have read and fully understand this policy. This document will be reviewed and updated by Management on an annual basis or when relevant to include newly developed security standards into the policy and re-distributed to all employees and contractors where applicable.

Dr. Nina, Inc. handles sensitive information daily. Sensitive Information must have adequate safeguards in place to protect the account data that includes cardholder data, cardholder privacy, and to ensure compliance with various regulations, along with guarding the future of the organisation.

Dr. Nina, Inc. commits to respecting the privacy of all its customers and to protecting any customer data from outside parties. To this end management are committed to maintaining a secure environment in which to process cardholder information so that we can meet these promises.

Employees handling sensitive cardholder data should ensure:

• Handle Company and account data information in a manner that fits with their sensitivity and classification;
• Limit personal use of Dr. Nina, Inc. information and telecommunication systems and ensure it doesn’t interfere with your job performance;
• Dr. Nina, Inc. reserves the right to monitor, access, review, audit, copy, store, or delete any electronic communications, equipment, systems and network traffic for any purpose;
• Do not use e-mail, internet and other Company resources to engage in any action that is offensive, threatening, discriminatory, defamatory, slanderous, pornographic, obscene, harassing or illegal;
• Do not disclose personnel information unless authorised;
• Protect sensitive account data including cardholder information;
• Keep passwords and accounts secure;
• Request approval from management prior to establishing any new software or hardware, third party connections, etc.;
• Do not install unauthorised software or hardware, including modems and wireless access unless you have explicit management approval;
• Always leave desks clear of sensitive cardholder data and lock computer screens when unattended;
• Information security incidents must be reported, without delay, to the individual responsible for incident response locally – Please find out who this is.
• Attend security awareness training on an annual basis

We each have a responsibility for ensuring our company’s systems and data are protected from unauthorised access and improper use. If you are unclear about any of the policies detailed herein you should seek advice and guidance from your line manager.

A high-level network diagram of the network is maintained and reviewed on a yearly basis. The network diagram provides a high level overview of the cardholder data environment (CDE), which at a minimum shows the connections in and out of the CDE. Critical system components within the CDE, such as POI/POS devices, databases, eCommerce web servers, re-direction/iFrame servers, etc., and any other necessary payment components, as applicable should also be illustrated.

In addition, ASV should be performed and completed by a PCI SSC Approved Scanning Vendoron a quarterly basis (every 90-92 days), where applicable. Evidence of these scans should be maintained for a period of 18 months. For eCommerce, the scans need to include the re-direction/iFrame servers at a minimum.

For standalone-dialup terminals:

For P2PE solutions:

For eCommerce that use re-direction/iFrame to a hosted payment page: see Appendix D

Management’s intentions for publishing an Acceptable Use Policy are not to impose restrictions that are contrary to Dr. Nina, Inc.’s established culture of openness, trust and integrity. Management is committed to protecting the employees, partners and Dr. Nina, Inc. from illegal or damaging actions, either knowingly or unknowingly by individuals. Dr. Nina, Inc. will maintain an approved list of technologies and devices and personnel with access to such devices as detailed in Appendix B.

• Employees are responsible for exercising good judgment regarding the reasonableness of personal use.
• Employees should take all necessary steps to prevent unauthorized access to confidential data which includes account data/card holder data.
• Keep passwords secure and do not share accounts. Authorized users are responsible for the security of their passwords and accounts.
• All PCs, laptops and workstations should be secured with a password-protected screensaver with the automatic activation feature.
• All POS and POI/PIN entry devices should be appropriately protected and secured so they cannot be tampered or altered.
• The List of Devices in Appendix B will be regularly updated when devices are modified, added or decommissioned. A stocktake of devices will be regularly performed and devices inspected to identify any potential tampering or substitution of devices.
• Users should be trained in the ability to identify any suspicious behaviour where any tampering or substitution may be performed. Any suspicious behaviour will be reported accordingly.
• Information contained on portable computers is especially vulnerable, special care should be exercised.
• Postings by employees from a Company email address to newsgroups should contain a disclaimer stating that the opinions expressed are strictly their own and not necessarily those of Dr. Nina, Inc., unless posting is in the course of business duties.
• Employees must use extreme caution when opening e-mail attachments received from unknown senders, which may contain viruses, e-mail bombs, Trojan horse code, or phishing attacks.

• Dr. Nina, Inc. and its employees are not to store cardholder data in form of PAN or sensitive authentication data in electronic format at all.
• All sensitive account data including cardholder data stored and handled in hard copy by Dr. Nina, Inc. and its employees must be securely protected against unauthorised use at all times. Any sensitive card data that is no longer required by
• Dr. Nina, Inc. for business reasons must be discarded in a secure and irrecoverable manner.
• If there is no specific need to see the full PAN (Primary Account Number), it has to be masked when displayed and showing six first and last four numbers of PAN maximum.
• PAN'S which are not protected as stated above should not be sent to the outside network via end user messaging technologies like email, chats, ICQ messenger etc.,

• The contents of the payment card magnetic stripe (track data) or chip equivalent track data on any media whatsoever.
• The CVV2/CVC2/CAV2/CID (the 3 or 4 digit number on the signature panel on the reverse of the payment card) on any media whatsoever.
• The PIN or the encrypted PIN Block under any circumstance.

Data and media containing data must always be labelled to indicate sensitivity level.

• Confidential data might include information assets for which there are legal requirements for preventing disclosure or financial penalties for disclosure, or data that would cause severe damage to Dr. Nina, Inc. if disclosed or modified.  Confidential data includes account data /  cardholder data.
• Internal Use data might include information that the data owner feels should be protected to prevent unauthorized disclosure.
• Public data is information that may be freely disseminated.

All Access to sensitive cardholder should be controlled and authorised. Any job functions that require access to cardholder data should be clearly defined.

• Any display of the account data / card holder should be restricted at a minimum to the first 6 and the last 4 digits of the primary account number (PAN) .
• Access to sensitive cardholder information such as PAN’s, personal information and business data is restricted to employees that have a legitimate need to view such information. 
• No other employees should have access to this confidential data unless they have a genuine business need. 
• If cardholder data is shared with a Service Provider (3rd party) then a list of such Service Providers will be maintained as detailed in Appendix C.
• Dr. Nina, Inc. will ensure a written agreement that includes an acknowledgement is in place that the Service Provider will be responsible for the for the cardholder data that the Third Party Service Provider (TPSP) possess.
• Dr. Nina, Inc. will ensure that a there is an established process, including proper due diligence is in place, before engaging with a TPSP.
•  Dr. Nina, Inc. will have a process in place to monitor the PCI DSS compliance status of the TPSP.
• Dr. Nina, Inc. need to ensure that the responsibilities for ensuring the security of account data / cardholder data is defined between Dr. Nina, Inc. and a TPSP. This need to be documented in a responsibility matrix.

Access to sensitive information in both hard and soft media format must be physically restricted to prevent unauthorised individuals from obtaining sensitive data. 

• Media is defined as any printed or handwritten paper, received faxes, floppy disks, back-up tapes, computer hard drive, etc.  
• Media containing sensitive cardholder information must be handled and distributed in a secure manner by trusted individuals.  
• Visitors must always be escorted by a trusted employee when in areas that hold sensitive cardholder information. 
• Procedures must be in place to help all personnel easily distinguish between employees and visitors, especially in areas where account data including cardholder data is accessible. “Employee” refers to full-time and part-time employees, temporary employees and personnel, and consultants who are “resident” on Company sites. A “visitor” is defined as a vendor, guest of an employee, service personnel, or anyone who needs to physically enter the premises for a short duration, usually not more than one day.
• A list of devices including the Point of Interaction (POI) Terminals that accept payment card data should be maintained.
• The list should include make, model and location of the device (POI).
• The list should have the serial number or a unique identifier of the device(POI).
• The list should be updated when devices (POI’s) are added, removed or relocated.
• POS devices surfaces are periodically inspected to detect tampering or substitution. 
• Personnel using the devices should be trained and aware of handling the POI devices
• Personnel using the devices should verify the identity of any third party personnel claiming to repair or run maintenance tasks on the devices (POI’s), install new devices (POI’s) or replace devices (POI’s).
• Personnel using the devices should be trained to report suspicious behaviour and indications of tampering of the devices (POI’s) to the appropriate personnel. Dr. Nina, Inc. sites. A “visitor” is defined as a vendor, guest of an employee, service personnel, or anyone who needs to enter the premises for a short duration, usually not more than one day.
• Strict control is maintained over the external or internal distribution of any media containing card holder data and has to be approved by management
• Strict control is maintained over the storage and accessibility of media.
• All computer that store sensitive cardholder data must have a password protected screensaver enabled to prevent unauthorised use.

All sensitive cardholder data must be protected securely if it is to be transported physically or electronically. 

• Card holder data (PAN, track data, etc.) must never be sent over the internet via email, instant chat or any other end user technologies.
• If there is a business justification to send cardholder data via email or by any other mode then it should be done after authorization and by using a strong encryption mechanism (i.e. – AES encryption, PGP encryption, IPSEC, etc.).    
• The transportation of media containing sensitive cardholder data to another location must be authorised by management, logged and inventoried before leaving the premises. Only secure courier services may be used for the transportation of such media. The status of the shipment should be monitored until it has been delivered to its new location.

• All data must be securely disposed of when no longer required by Dr. Nina, Inc., regardless of the media or application type on which it is stored.
• An automatic process must exist to permanently delete on-line data, when no longer required.
• All hard copies of cardholder data must be manually destroyed when no longer required for valid and justified business reasons. A quarterly process must be in place to confirm that all non-electronic cardholder data has been appropriately disposed of in a timely manner.
• Dr. Nina, Inc. will have procedures for the destruction of hardcopy (paper) materials. These will require that all hardcopy materials are crosscut shredded, incinerated or pulped so they cannot be reconstructed.
• Dr. Nina, Inc. will have documented procedures for the destruction of electronic media. These will require:
  • All cardholder data on electronic media must be rendered unrecoverable when deleted e.g. through degaussing or electronically wiped using military grade secure deletion processes or the physical destruction of the media;
  • If secure wipe programs are used, the process must define the industry accepted standards followed for secure deletion.
• All cardholder information awaiting destruction must be held in lockable storage containers clearly marked “To Be Shredded” - access to these containers must be restricted.

The policies and procedures outlined below must be incorporated into company practice to maintain a high level of security awareness. The protection of sensitive data demands regular training of all employees and contractors.

• Review handling procedures for sensitive information and hold periodic security awareness meetings to incorporate these procedures into day to day company practice.
• Distribute this security policy document to all company employees to read. It is required that all employees confirm that they understand the content of this security policy document by signing an acknowledgement form (see Appendix A).
• All employees that handle sensitive information will undergo background checks (such as criminal and credit record checks, within the limits of the local law) before they commence their employment with Dr. Nina, Inc..
• All third parties with access to credit card account numbers are contractually obligated to comply with card association security standards (PCI/DSS).
• Company security policies must be reviewed annually and updated as needed.

• Dr. Nina, Inc. PCI Security Incident Response Team (PCI Response Team) is comprised of the Information Security Officer and Merchant Services. Dr. Nina, Inc. PCI security incident response plan is as follows:
  1. Each department must report an incident to the Information Security Officer (preferably) or to another member of the PCI Response Team.
     That member of the team receiving the report will advise the PCI Response Team of the incident.
  2. The PCI Response Team will investigate the incident and assist the potentially compromised department in limiting the exposure of cardholder data and in mitigating the risks associated with the incident.
  3. The PCI Response Team will resolve the problem to the satisfaction of all parties involved, including reporting the incident and findings to the appropriate parties (credit card associations, credit card processors, etc.) as necessary.
  4. The PCI Response Team will determine if policies and processes need to be updated to avoid a similar incident in the future, and whether additional safeguards are required in the environment where the incident occurred, or for the institution.
• Dr. Nina, Inc. PCI Security Incident Response Team (or equivalent in your organisation):

CIO
Communications Director
Compliance Officer
Counsel
Information Security Officer
Collections & Merchant Services
Risk Manager

• Information Security PCI Incident Response Procedures:
  • A department that reasonably believes it may have an account breach, or a breach of cardholder information or of systems related to the PCI environment in general, must inform Dr. Nina, Inc. PCI Incident Response Team. After being notified of a compromise, the PCI Response Team, along with other designated staff, will implement the PCI Incident Response Plan to assist and augment departments’ response plans.

In response to a systems compromise, the PCI Response Team and designees will:

1. Ensure compromised system/s is isolated on/from the network.
2. Gather, review and analyze the logs and related information from various central and local safeguards and security controls
3. Conduct appropriate forensic analysis of compromised system.
4. Contact internal and external departments and entities as appropriate.
5. Make forensic and log analysis available to appropriate law enforcement or card industry security personnel, as required.
6. Assist law enforcement and card industry security personnel in investigative processes, including in prosecutions.

The credit card companies have individually specific requirements that the Response Team must address in reporting suspected or confirmed breaches of cardholder data. See below for these requirements.

Incident Response notifications to various card schemes

1. In the event of a suspected security breach, alert the information security officer or your line manager immediately.
2. The security officer will carry out an initial investigation of the suspected security breach.
3. Upon confirmation that a security breach has occurred, the security officer will alert management and begin informing all relevant parties that may be affected by the compromise.

If the data security compromise involves credit card account numbers, implement the following procedure:

• Shut down any systems or processes involved in the breach to limit the extent, and prevent further exposure.
• Alert all affected parties and authorities such as the Merchant Bank (your Bank), Visa Fraud Control, and the law enforcement.
  Provide details of all compromised or potentially compromised card numbers to
• Visa Fraud Control within 24 hrs.
• For more Information visit: http://usa.visa.com/business/accepting_visa/ops_risk_management/cisp_if_ compromised.html

This report must be provided to VISA within 14 days after initial report of incident to VISA. The following report content and standards must be followed when completing the incident report. Incident report must be securely distributed to VISA and Merchant Bank. Visa will classify the report as “VISA Secret”*.

1. Executive Summary
   1. Include overview of the incident
   2. Include RISK Level(High, Medium, Low)
   3. Determine if compromise has been contained
2. Background
3. Initial Analysis
4. Investigative Procedures
   1. Include forensic tools used during investigation
5. Findings
   1. Number of accounts at risk, identify those stores and compromised
   2. Type of account information at risk
   3. Identify ALL systems analyzed. Include the following:
      • Domain Name System (DNS) names
      • Internet Protocol (IP) addresses
      • Operating System (OS) version
      • Function of system(s)
   4. Identify ALL compromised systems. Include the following:
      • DNS names
      • IP addresses
      • OS version
      • Function of System(s)
   5. Timeframe of compromise
   6. Any data exported by intruder
   7. Establish how and source of compromise
   8. Check all potential database locations to ensure that no CVV2, Track 1 or Track 2 data is stored anywhere, whether encrypted or unencrypted (e.g., duplicate or backup tables or databases, databases used in development, stage or testing environments, data on software engineers’ machines, etc.)
   9. If applicable, review VisaNet endpoint security and determine risk
6. Compromised Entity Action
7. Recommendations
8. Contact(s) at entity and security assessor performing investigation

1. Within 24 hours of an account compromise event, notify the MasterCard Compromised Account Team via phone at 1-636-722-4100.
2. Provide a detailed written statement of fact about the account compromise (including the contributing circumstances) via secured e-mail to [email protected].
3. Provide the MasterCard Merchant Fraud Control Department with a complete list of all known compromised account numbers.
4. Within 72 hours of knowledge of a suspected account compromise, engage the services of a data security firm acceptable to MasterCard to assess the vulnerability of the compromised data and related systems (such as a detailed forensics evaluation).
5. Provide weekly written status reports to MasterCard, addressing open questions and issues until the audit is complete to the satisfaction of MasterCard.
6. Promptly furnish updated lists of potential or known compromised account numbers, additional documentation, and other information that MasterCard may request.
7. Provide finding of all audits and investigations to the MasterCard Merchant Fraud Control department within the required time frame and continue to address any outstanding exposure or recommendation until resolved to the satisfaction of MasterCard.

Once MasterCard obtains the details of the account data compromise and the list of compromised account numbers, MasterCard will:

1. Identify the issuers of the accounts that were suspected to have been compromised and group all known accounts under the respective parent member IDs.
2. Distribute the account number data to its respective issuers.

Employees of Dr. Nina, Inc. will be expected to report to the security officer for any security related issues. The role of the security officer is to effectively communicate all security policies and procedures to employees within Dr. Nina, Inc. and contractors. In addition to this, the security officer will oversee the scheduling of security training sessions, monitor and enforce the security policies outlined in both this document and at the training sessions and finally, oversee the implantation of the incident response plan in the event of a sensitive data compromise.

1. Within 24 hours of an account compromise event, notify Discover Fraud
2. Prevention at (800) 347-3102
3. Prepare a detailed written statement of fact about the account compromise including the contributing circumstances
4. Prepare a list of all known compromised account numbers
5. Obtain additional specific requirements from Discover Card

1. Within 24 hours of an account compromise event, notify American Express
2. Merchant Services at (800) 528-5200 in the U.S.
3. Prepare a detailed written statement of fact about the account compromise including the contributing circumstances
4. Prepare a list of all known compromised account numbers Obtain additional specific requirements from American Express

• All third-party companies providing critical services to Dr. Nina, Inc. must provide an agreed Service Level Agreement.
• All third-party companies providing hosting facilities must comply with Dr. Nina,
• Inc.’s Physical Security and Access Control Policy.
• All third-party companies which have access to Card Holder information must
  
  
  1. Adhere to the PCI DSS security requirements.
  2. Acknowledge their responsibility for securing the Card Holder data.
  3. Acknowledge that the Card Holder data must only be used for assisting the completion of a transaction, supporting a loyalty program, providing a fraud control service or for uses specifically required by law.
  4. Have appropriate provisions for business continuity in the event of a major disruption, disaster or failure.
  5. Provide full cooperation and access to conduct a thorough security review after a security intrusion by a Payment Card industry representative, or a
  6. Payment Card industry approved third party.

• Access to Company is controlled through a formal user registration process beginning with a formal notification from HR or from a line manager.
• Each user is identified by a unique user ID so that users can be linked to and made responsible for their actions. The use of group IDs is only permitted where they are suitable for the work carried out.
• There is a standard level of access; other services can be accessed when specifically authorized by HR/line management.
• The job function of the user decides the level of access the employee has to cardholder data
• A request for service must be made in writing (email or hard copy) by the newcomer’s line manager or by HR. The request is free format, but must state:
  
  Name of person making request;
  Job title of the newcomers and workgroup;
  Start date;
  Services required (default services are: MS Outlook, MS Office and Internet access).
  
  
• Each user will be given a copy of their new user form to provide a written statement of their access rights, signed by an IT representative after their induction procedure. The user signs the form indicating that they understand the conditions of access.
• Access to all Dr. Nina, Inc. systems is provided by IT and can only be started after proper procedures are completed.
• As soon as an individual leaves Dr. Nina, Inc. employment, all his/her system logons must be immediately revoked and account must be disabled and removed.
• As part of the employee termination process HR (or line managers in the case of contractors) will inform IT operations of all leavers and their date of leaving.

• Access Control systems are in place to protect the interests of all users of Dr. Nina, Inc. computer systems by providing a safe, secure and readily accessible environment in which to work.
• Dr. Nina, Inc. will provide all employees and other users with the information they need to carry out their responsibilities in an as effective and efficient manner as possible.
• Generic or group IDs shall not normally be permitted, but may be granted under exceptional circumstances if sufficient other controls on access are in place.
• The allocation of privilege rights (e.g. local administrator, domain administrator, super-user, root access) shall be restricted and controlled, and authorization provided jointly by the system owner and IT Services. Technical teams shall guard against issuing privilege rights to entire teams to prevent loss of confidentiality.
• Access rights will be accorded following the principles of least privilege and need to know.
• Every user should attempt to maintain the security of data at its classified level even if technical security mechanisms fail or are absent.
• Users electing to place information on digital media or storage devices or maintaining a separate database must only do so where such an action is in accord with the data’s classification.
• Users are obligated to report instances of non-compliance to Dr. Nina, Inc. CISO.
• Access to Dr. Nina, Inc. IT resources and services will be given through the provision of a unique Active Directory account and complex password.
• No access to any Dr. Nina, Inc. IT resources and services will be provided without prior authentication and authorization of a user’s Dr. Nina, Inc.
• Windows Active Directory account.
• Password issuing, strength requirements, changing and control will be managed through formal processes. Password length, complexity and expiration times will be controlled through Windows Active Directory Group Policy Objects.
  
  • Password: 8 Characters, Complex, Unique and Change at first use, not re-usable, change every 90 days.
• Access to Confidential, Restricted and Protected information will be limited to authorised persons whose job responsibilities require it, as determined by the data owner or their designated representative. Requests for access permission to be granted, changed or revoked must be made in writing.
• Users are expected to become familiar with and abide by Dr. Nina, Inc. policies, standards and guidelines for appropriate and acceptable usage of the networks and systems.
• Access for remote users shall be subject to authorization by IT Services and be provided in accordance with the Remote Access Policy and the Information
• Security Policy. No uncontrolled external access shall be permitted to any network device or networked system.
• Access to data is variously and appropriately controlled according to the data classification levels described in the Information Security Management Policy.
• Access control methods include logon access rights, Windows share and NTFS permissions, user account privileges, server and workstation access rights, firewall permissions, IIS intranet/extranet authentication rights, SQL database rights, isolated networks and other methods as necessary.
• A formal process shall be conducted at regular intervals by system owners and data owners in conjunction with IT Services to review users’ access rights. The review shall be logged and IT Services shall sign off the review to give authority for users’ continued access rights.

Where Dr. Nina, Inc. are utilizing standalone and P2PE POI’s the following policies are applicable:

POI Device Inventory and Management:

• Maintain an up-to-date inventory of all POI devices, including make, model, location, and serial number.
• Establish procedures for securely adding, relocating, and decommissioning POI devices.

Physical Security Measures:

• Secure POI devices to prevent tampering or substitution. This includes using tamper-evident seals or enclosures.
• Regularly inspect devices for signs of tampering or substitution.
• Implement secure storage for devices not in use.

Device Inspection and Maintenance:

• Conduct regular inspections and maintenance of POI devices to ensure they are functioning correctly and haven't been compromised.
• Document and maintain a record of all inspections and maintenance activities.

Secure Configuration and Software Management:

• Ensure that POI devices are configured securely and in compliance with PCI DSS requirements.
• Implement measures to prevent unauthorized changes to software and configuration settings.
• Regularly update POI device software, including patches for known vulnerabilities.

Access Controls:

• Restrict access to POI devices to authorized personnel only.
• Use strong authentication methods for administrative access to POI devices.
• Implement role-based access controls and segregate duties to minimize the risk of unauthorized access or changes.

Where Dr. Nina, Inc. are utilizing re-direct and iFrame solutions to take payments for the eCommerce environment Dr. Nina, Inc. need to apply system configuration and hardening of these systems as follows:

Establish a Standard eCommerce Server Configuration:

• Define a standard configuration for servers that includes necessary services, protocols, and settings.
• Ensure that vendor default accounts are changed, removed or disabled.
• Disable unnecessary services and protocols to minimize vulnerabilities.
• Ensure that all security settings are aligned with industry best practices.

Implement Hardening Procedures:

• Implement strong authentication and authorization mechanisms.
• Use file integrity monitoring tools to detect unauthorized changes.
• Enforce the use of antivirus and anti-malware solutions.

Control Administrative Access:

• Limit access to server configurations to authorized personnel only.
• Use multi-factor authentication for administrative access.
• Maintain an audit trail of all access and changes made to server configurations.

Regularly Review and Update Configurations:

• Periodically review server configurations against the established standard.
• Update the configurations in response to new threats, vulnerabilities, or changes in organizational needs.

Maintain a Vulnerability Management Program:

• Regularly scan for vulnerabilities and address identified weaknesses.
• Include both software and physical components in your vulnerability assessments.
• Establish a process to check for new security vulnerabilities and include the following:
  
  • Industry recognized sources
  • Risk ranking process based on industry best practices and identification of vulnerabilities that are high risk.
• Regularly update and patch operating systems and software to fix vulnerabilities.
• Ensure to apply applicable security patches within one month from release.