HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact KKV’s HIPAA/Privacy Officer at (808) 791-9417.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to:

• individually identifiable protected health information created by your personal doctor or others working in this health center;

• individually identifiable protected health records received by us related to past, present, or future physical or mental health condition of an individual;

• the provision of health care to an individual;

• the past, present, or future payment for the provision of health care to an individual; and/or

• the information that identifies the individual, or for which there is a reasonable basis to believe the information can be used to identify the individual (herein after referred to as “protected health information”).

This notice applies to all of the records of your care by KKV. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

• Make sure that health information that identifies you is kept private;

• Give you this notice of our legal duties and privacy practices with respect to health information about you; and

• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take X-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because it may slow the healing process. In addition, the doctor may need to tell the dietician at the hospital if you have diabetes so that we can arrange for appropriate meals. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, insurance company, or a third party. For example, we may need to give your health plan information about your visit in the office or via telehealth so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Heath Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment. With recent trends in technology, we have started to deploy on-line portals along with HIPAA secure mobile, multidirectional, multimedia smart phone technology. Please let us know if you do not wish to have us contact you concerning your appointment, or if you do not wish to have us use a different number or address to contact you for this purpose. Any added features mentioned above will have the option for you to opt-out if you do not want to participate.

Fundraising Activities: We may use health information about you to contact you in an effort to raise money for our not-for-profit operations. We may disclose health information to a foundation related to our practice so that the foundation may contact you in raising money for our practice. We only release contact information, such as your name, address, and phone number. You have the right to opt-out if you do not want us to contact you for such fundraising efforts.

As required by Law: We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans: If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable.

Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose health information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury, or disability;

• To report births and deaths;

• To report child abuse or neglect;

• To report vulnerable adult abuse or neglect;

• To report reactions to medications or overall problems;

• To notify people of recalls of products they may be using;

• To notify person or organization required to receive information on FDA-regulated products;

• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do so by a law enforcement official:

• In reporting certain injuries as required by law, e.g. injuries caused by the use of violence, sustained in a suspicious or unusual manner, or in motor vehicle collisions.

• In response to a court order, subpoena, warrant, summons, or missing person;

• To identify or locate a locate a subject, fugitive, material witness, or missing person: o Name and address

o Date of birth or place of birth

o Social security number

o Blood type or Rh factor

o Type of injury

o Date and time of treatment and /or death, if applicable

o A description of distinguishing physical characteristics

• About the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person’s agreement;

• About a death we believe may be the result of criminal conduct;

• About criminal conduct at our facility;

• In emergency circumstances to report a crime: the location of the crime or victims, the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors: We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the president, other authorized persons or foreign heads of state or conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

All other categories and situations regarding your health information will NOT be released until we have written authorization from you. This would include disclosure for marketing purposes and other areas which constitute the sale of PHI, most uses and disclosures of psychotherapy notes and other uses and disclosures not described in the notice.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding health information we maintain about you:

Right to Access, Inspect, and Copy: You have the right to inspect and access and/or copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. It is also the policy of KKV to comply with the 21st Century Cures Act Information Blocking Final Rule. All requests to access, exchange, or use of Electronic Health Information (EHI) submitted to KKV will be fulfilled unless Federal, State, or Tribal law prohibit disclosure or the request falls within any of the outlined exceptions set forth under the Office of the National Coordinator for Health Information Technology (ONC) Cures Act Final Rule. All requests to access, exchange or use of Electronic Health Information (EHI) will be tracked and documented throughout the entirety of the process by the department responsible for fulfillment of the request and completed in a timely manner. If KKV is unable to fulfill request, documentation of reason(s) why the request was not fulfilled will be maintained.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Medical Records Department at Kokua Kalihi Valley CFS, 2239 N. School Street, Honolulu, HI 96819. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If KKV is unable to fulfill request, documentation of reason(s) why the request was not fulfilled will be maintained. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we have the information. To request an amendment, your request must be made in writing, submitted to our HIPAA/Privacy Officer at Kokua Kalihi Valley CFS, 2239 N. School Street, Honolulu, HI 96819, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason that supports your request for an amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

• is not part of the health information kept by or for our practice;

• is not part of the information which you would be permitted to inspect and copy; or

• is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to our HIPAA/Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 15, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You have the right to restrict disclosure when payment is in full out of pocket. For example, if you had doctor visit which you did not want to disclose to your health insurance and paid out of pocket in full this information would not be shared. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, or that we do not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to our HIPAA/Privacy Officer. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.

To request confidential communications, you must make your request in writing to our HIPAA/Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from the intake desk. You may also obtain a copy of this notice from our website at www.kkv.net.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised notice effective for health information we already have about you as well as any information we receive in the future. We will have a copy of the current notice posted in our facility. The notice will contain on the first page, the revised date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our HIPAA/Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE

We will request that you sign a separate form (Registration) or notice acknowledging you have received a copy of this notice. If you choose or are not able to sign, a staff member will sign his/her name and date. This acknowledgement will be filed with your records.

KKV HIPAA Notice of Privacy Practices (Effective: April 10, 2003; Revised: 10.24.11, 9.28.14, 9.5.18, 9.9.21, 9.14.23)