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Notice of Privacy Policy


As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)




Our practice is dedicated to maintaining the privacy of your individually protected health information
(IPHI). In conducting our business, we will create records regarding you and the treatment and
services we provide to you. We are required by law to maintain the confidentiality of health information
that identifies you. We also are required by law to provide you with this notice of our legal duties and the
privacy practices that we maintain in our practice concerning your IPHI. By federal and state law, we
must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important

  • How we may use and disclose your IPHI

  • Your privacy rights in your IPHI

  • Our obligations concerning the use and disclosure of your IPHI

The terms of this notice apply to all records containing your IPHI that are created or retained by our
practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or
amendment to this notice will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.


Privacy Officer
40 Aulike Street, Suite 317
Kailua, HI 96734


The following categories describe the different ways in which we may use and disclose your IPHI.

1. Treatment. Our practice may use your IPHI to treat you. For example, we may ask you to have
laboratory tests (such as blood or urine tests), and we may use the results to help us reach a
We might use your IPHI in order to write a prescription for you, or we might disclose your IPHI to a
pharmacy when we order a prescription for you. Many of the people who work for our practice -
including, but not limited to, our doctors and nurses - may use or disclose your IPHI in order to treat
you or to assist others in your treatment. Additionally, we may disclose your IPHI to others who may
assist in your care, such as your spouse, children or parents.
Finally, we may also disclose your IPHI to other health care providers for purposes related to your

2. Payment. Our practice may use and disclose your IPHI in order to bill and collect payment for the
services and items you may receive from us. For example, we may contact your health insurer to
certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer
with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We
also may use and disclose your IPHI to obtain payment from third parties that may be responsible for
such costs, such as family members. Also, we may use your IPHI to bill you directly for services and
items. We may disclose your IPHI to other health care providers and entities to assist in their billing
and collection efforts.

3. Health Care Operations. Our practice may use and disclose your IPHI to operate our business. As
examples of the ways in which we may use and disclose your information for our operations, our
practice may use your IPHI to evaluate the quality of care you received from us, or to conduct cost-
management and business planning activities for our practice. We may disclose your IPHI to other health care
providers and entities to assist in their health care operations.

4. Appointment Reminders. Our practice may use and disclose your IPHI to contact you and remind
you of an appointment.

5. Treatment Options. Our practice may use and disclose your IPHI to inform you of potential
treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your IPHI to inform you of
health-related benefits or services that may be of interest to you.

7. Release of Information to Family/Friends. Our practice may release your IPHI to a friend or family
member that is involved in your care, or who assists in taking care of you. For example, a parent or
guardian may ask that a babysitter take their child to the pediatrician's office for treatment of a cold.
In this example, the babysitter may have access to this child's medical information. If you object to the
release of this information, please talk to us.

8. Disclosures Required By Law. Our practice will use and disclose your IPHI when we are required to
do so by federal, state or local law.


The following categories describe unique scenarios in which we may use or disclose your identifiable
health information:

1. Public Health Risks. Our practice may disclose your IPHI to public health authorities that are
authorized by law to collect information for the purpose of:

  • maintaining vital records, such as births and deaths

  • reporting child abuse or neglect

  • preventing or controlling disease, injury or disability

  • notifying a person regarding potential exposure to a communicable disease

  • notifying a person regarding a potential risk for spreading or contracting a disease or condition

  • reporting reactions to drugs or problems with products or devices

  • notifying individuals if a product or device they may be using has been recalled

  • notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult
    patient (including domestic violence);
    however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this

  • notifying your employer under limited circumstances related primarily to workplace injury or illness
    or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your IPHI to a health oversight agency for
activities authorized by law. Oversight activities can include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or
actions; or other activities necessary for the government to monitor government programs, compliance
with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IPHI in response to a
court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may
disclose your IPHI in response to a discovery request, subpoena, or other lawful process by another party
involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested.

4. Law Enforcement. We may release IPHI if asked to do so by a law enforcement official:

  • Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement

  • Concerning a death we believe has resulted from criminal conduct

  • Regarding criminal conduct at our offices

  • In response to a warrant, summons, court order, subpoena or similar legal process

  • To identify/locate a suspect, material witness, fugitive or missing person

  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

  • 5. Deceased Patients. Our practice may release IPHI to a medical examiner or coroner to identify a
    deceased individual or to identify the cause of death. If necessary, we also may release information in
    order for funeral directors to perform their jobs.

    6. Organ and Tissue Donation. Our practice may release your IPHI to organizations that handle
    organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to
    facilitate organ or tissue donation and transplantation if you are an organ donor.

    7. Research. Our practice may use and disclose your IPHI for research purposes in certain limited
    circumstances. We will obtain your written authorization to use your IPHI for research purposes
    except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization
    satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy
    based on the following: (A) an adequate plan to protect the identifiers from improper use and
    disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with
    the research (unless there is a health or research justification for retaining the identifiers or such retention
    is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or
    disclosed to any other person or entity (except as required by law) for authorized oversight of the
    research study, or for other research for which the use or disclosure would otherwise be permitted; (ii)
    the research could not practicably be conducted without the waiver; and (iii) the research could not
    practicably be conducted without access to and use of the PHI.

    8. Serious Threats to Health or Safety. Our practice may use and disclose your IPHI when necessary
    to reduce or prevent a serious threat to your health and safety or the health and safety of another
    individual or the public. Under these circumstances, we will only make disclosures to a person or
    organization able to help prevent the threat.

    9. Military. Our practice may disclose your IPHI if you are a member of U.S. or foreign military forces
    (including veterans) and if required by the appropriate authorities.

    10. National Security. Our practice may disclose your IPHI to federal officials for intelligence and
    national security activities authorized by law. We also may disclose your IPHI to federal officials in
    to protect the President, other officials or foreign heads of state, or to conduct investigations.

    11. Inmates. Our practice may disclose your IPHI to correctional institutions or law enforcement
    officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes
    would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and
    security of the institution, and/or (c) to protect your health and safety or the health and safety of other

    12. Workers' Compensation. Our practice may release your IPHI for workers' compensation and
    similar programs.


    You have the following rights regarding the IPHI that we maintain about you:

    1. Confidential Communications. You have the right to request that our practice communicate with you
    about your health and related issues in a particular manner or at a certain location. For instance, you
    may ask that we contact you at home, rather than work. In order to request a type of confidential
    communication, you must make a written request to Privacy Officer, 808-263-8822 specifying the
    requested method of contact, or the location where you wish to be contacted. Our practice will
    accommodate reasonable requests. You do not need to give a reason for your request.

    2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your
    IPHI for treatment, payment or health care operations. Additionally, you have the right to request that
    we restrict our disclosure of your IPHI to only certain individuals involved in your care or the payment
    for your care, such as family members and friends. We are not required to agree to your request;
    however, if we do agree, we are bound by our agreement except when otherwise required by law, in
    emergencies, or when the information is necessary to treat you. In order to request a restriction in
    our use or disclosure of your IPHI, you must make your request in writing to: Privacy Officer, 808-263-

    Your request must describe in a clear and concise fashion:

    (a) the information you wish restricted;
    (b) whether you are requesting to limit our practice's use, disclosure or both; and
    (c) to whom you want the limits to apply.

    3. Inspection and Copies. You have the right to inspect and obtain a copy of the IPHI that may be
    used to make decisions about you, including patient medical records and billing records, but not including
    psychotherapy notes. You must submit your request in writing to Privacy Officer, 808-263-8822 in
    order to inspect and/or obtain a copy of your IPHI. Our practice may charge a fee for the costs of copying,
    mailing, labor and supplies associated with your request. Our practice may deny your request to
    inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another
    licensed health care professional chosen by us will conduct reviews.

    4. Amendment. You may ask us to amend your health information if you believe it is incorrect or
    incomplete, and you may request an amendment for as long as the information is kept by or for our
    practice. To request an amendment, your request must be made in writing and submitted to Privacy
    Officer, 808-263-8822. You must provide us with a reason that supports your request for amendment.
    Our practice will deny your request if you fail to submit your request (and the reason supporting your
    request) in writing. Also, we may deny your request if you ask us to amend information that is in our
    opinion: (a) accurate and complete; (b) not part of the IPHI kept by or for the practice; (c) not part of
    the IPHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the
    individual or entity that created the information is not available to amend the information.

    5. Accounting of Disclosures. All of our patients have the right to request an "accounting of
    disclosures." An "accounting of disclosures" is a list of certain disclosures (usually required by law) our
    practice has made of your IPHI for non-treatment, non-payment or non-operations purposes. Use of
    your IPHI as part of the routine patient care in our practice is not required to be documented. For
    example, the doctor sharing information with the nurse; or the billing department using your
    information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your
    request in writing to Privacy Office, 808-263-8822. All requests for an "accounting of disclosures" must
    state a time period, which may not be longer than six (6) years from the date of disclosure and may
    not include dates before April 14, 2003. The first list you request within a 12-month period is free of
    charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will
    notify you of the costs involved with additional requests, and you may withdraw your request before
    you incur any costs.

    6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of
    privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this
    notice, contact Privacy Officer, 808-263-8822.

    7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a
    complaint with our practice or with the Secretary of the Department of Health and Human Services. To
    file a complaint with our practice, contact Privacy Officer, 808-263-8822. All complaints must be
    submitted in writing. You will not be penalized for filing a complaint.

    8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your
    written authorization for uses and disclosures that are not identified by this notice or permitted by
    applicable law. Any authorization you provide to us regarding the use and disclosure of your IPHI may
    be revoked at any time in writing. After you revoke your authorization, we will no longer use or
    disclose your IPHI for the reasons described in the authorization. Please note, we are required to retain
    records of your care.

    Again, if you have any questions regarding this notice or our health information privacy policies, please
    contact Privacy Officer, 808-263-8822.