THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. IT ALSO DESCRIBES HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This practice respects its legal obligation to keep health information that identifies you private. I am obligated by law to give you notice of my privacy practices. This Notice describes how this practice protects your health information and what rights you have regarding it.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
- “PHI” refers to information in your health record that could identify you, as defined in 45 CFR § 106.103.
- “Treatment, Payment and Health Care Operations” – Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician, psychiatrist, psychologist or therapist. – Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. – Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
- “Use” applies only to activities within my practice group such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of my practice group, such as releasing, transferring, or providing access to information about you to other parties.
- “Patient” and “Client” refer to the recipient of therapeutic services in this practice and these two terms are used interchangeably in this Notice.
USES AND DISCLOSURES REQUIRING AUTHORIZATION
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing certain notes I have made about our conversation during a private, group, joint, or family counseling session, which I may have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION
I may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse – If I have reason to believe that child abuse or neglect has occurred or that there exists a substantial risk that child abuse or neglect may occur in the reasonably foreseeable future, I must immediately report the matter to the appropriate authority.
- Adult and Domestic Abuse – If I, in the performance of their professional or official duties, know or have reason to believe that a dependent adult has been abused and is threatened with imminent abuse, I must promptly report the matter to the appropriate authority.
- Health Oversight Activities – If the professional board or authority is investigating my competency, license or practice, I may be required to disclose protected health information regarding you.
- Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the counseling or psychotherapy services provided to you and/or the records thereof, such information is privileged under Hawaii law, and I shall not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I shall inform you in advance if this is the case.
- Serious Threat to Public Health or Safety – I may disclose protected health information regarding you where there is clear and imminent danger to you or another individual or to society, and then only to appropriate professional workers or public authorities. If you are at risk, I may also contact family members or others who could assist in providing protection.
- Worker’s Compensation – If you have filed a worker’s compensation claim, I may be required to disclose PHI about any services I have provided to you that are relevant to the claimed injury.
- De-Identified PHI – PHI that has been de-identified pursuant to 45 CFR § 164.514 may be disclosed for various purposes, such as, but not limited to, research or sharing with other health care providers.
There are additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common. For more information on other ways your PHI may be shared visit: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html
PATIENT’S RIGHTS AND OUR DUTIES
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
- Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
- Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.
- Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
- Right to a copy of this Privacy Notice – You may receive a copy of this notice.
- Right to choose someone to act for you – You have the right to choose someone to act on your behalf with a medical power of attorney or as a legal guardian.
- I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
- I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will notify you accordingly. I will usually provide you with the revision during an in-person meeting, but if necessary, I will send you the revision via postal mail, or electronic mail.
QUESTIONS AND COMPLAINTS
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact us at (808) 664-0638.
If you believe that your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to:
The ohana retreat, LLC
75-5915 Walua Rd.
Kailua Kona, HI 96740
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
Department of Health and Human Services, Office of Civil Rights,
Hubert H. Humphrey Building 200 Independence Avenue
S.W. Room 509 HHH Building
Washington, D.C. 20201
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.