Return to flip book view

We are required by law to maintain the privacy andsecurity of your protected health information.We will let you know promptly if a breach occurs thatmay have compromised the privacy or security of yourinformation.We must follow the duties and privacy practicesdescribed in this notice and give you a copy of it.We will not use or share your information other than asdescribed here unless you tell us we can in writing. Ifyou tell us we can, you may change your mind at anytime. Let us know in writing if you change your mind.For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlThis notice describes how medicalinformation about you may be used anddisclosed and how you can get access tothis information. Please review it carefully.We can change the terms of this notice, and the changeswill apply to all information we have about you. The newnotice will be available upon request, in our office, and onour web site.This Notice of Privacy Practices applies to the followingorganization Krizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comDesigned by Krizia Baldon via CanvaWith information from Compliancy Group: Notice of Privacy PracticesApril 12, 2024 You have the right to:Get a copy of your paper or electronic medical recordCorrect your paper or electronic medical recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we’ve shared yourinformationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights havebeen violated➤ See inside left panel for more information on these rightsand how to exercise themYou have some choices in the way that we use and shareinformation as we:Tell family and friends about your condition ฀ Provide disaster reliefInclude you in a hospital directoryProvide mental health careMarket our services and sell your informationRaise funds➤ See inside middle panel for more information on thesechoices and how to exercise themWe may use and share information as we:Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo researchComply with the lawRespond to organ and tissue donation requestsWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, andother government requestsRespond to lawsuits and legal actions➤ See inside middle and right panels for more informationon these choices and how to exercise themKrizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comChanges to the Terms of this Notice

When it comes to your health information, youhave certain rights. This section explains your rights and some of ourresponsibilities to help you. Get an electronic or paper copy of your medical recordYou can ask to see or get an electronic or paper copy of yourmedical record and other health information we have about you.Ask us how to do this.We will provide a copy or a summary of your health information,usually within 30 days of your request. We may charge areasonable, cost-based fee.Ask us to correct your medical recordYou can ask us to correct health information about you that youthink is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writingwithin 60 days.Request confidential communicationsYou can ask us to contact you in a specific way (for example,home or office phone) or to send mail to a different address.We will say “yes” to all reasonable requests.Ask us to limit what we use or shareYou can ask us not to use or share certain health information fortreatment, payment, or our operations. We are not required toagree to your request, and we may say “no” if it would affect yourcare.If you pay for a service or health care item out-of-pocket in full,you can ask us not to share that information for the purpose ofpayment or our operations with your health insurer. We will say“yes” unless a law requires us to share that information.Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of the times we’ve shared yourhealth information for six years prior to the date you ask, who weshared it with, and why.We will include all the disclosures except for those abouttreatment, payment, and health care operations, and certainother disclosures (such as any you asked us to make). We’llprovide one accounting a year for free but will charge areasonable, cost-based fee if you ask for another one within 12months.Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even ifyou have agreed to receive the notice electronically. We willprovide you with a paper copy promptly.Choose someone to act for youIf you have given someone medical power of attorney or ifsomeone is your legal guardian, that person can exercise yourrights and make choices about your health information.We will make sure the person has this authority and can act foryou before we take any action.฀File a complaint if you feel your rights are violated฀ You can complain if you feel we have violated your rights bycontacting us using the information on the front panel and backpanel of this brochure. ฀You can file a complaint with the U.S. Department of Health andHuman Services Office for Civil Rights by sending a letter to 200Independence Avenue, S.W., Washington, D.C., 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.htmlWe will not retaliate against you for filing a complaint. For certain health information, you can tell us yourchoices about what we share. If you have a clearpreference for how we share your information in thesituations described below, talk to us. Tell us whatyou want us to do, and we will follow yourinstructions.In these cases, you have both the right and choice to tell usto:Share information with your family, close friends, orothers involved in your careShare information in a disaster relief situationInclude your information in a hospital directoryIf you are not able to tell us your preference, for example if youare unconscious, we may go ahead and share your informationif we believe it is in your best interest. We may also share yourinformation when needed to lessen a serious and imminentthreat to health or safety.In these cases we never share your information unless yougive us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notesIn the case of fundraising:We may contact you for fundraising efforts, but you cantell us not to contact you again.How do we typically use or share your healthinformation?We typically use or share your health information inthe following ways.Run our organization We can use and share your health information to run ourpractice, improve your care, and contact you when necessary. Example: We use health information about you to manage yourtreatment and services.Bill for your servicesWe can use and share your health information to bill and getpayment from health plans or other entities.Example: We give information about you to your health insuranceplan so it will pay for your services.฀ ฀฀ ฀How else can we use or share your health information? We are allowed or required to share your information in other ways– usually in ways that contribute to the public good, such as publichealth and research. We have to meet many conditions in the law before we can shareyour information for these purposes. For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlHelp with public health and safety issues We can share health information about you for certain situationssuch as:Preventing diseaseHelping with product recallsReporting adverse reactions to medicationsReporting suspected abuse, neglect, or domestic violencePreventing or reducing a serious threat to anyone’s health orsafetyDo researchWe can use or share your information for health researchComply with the lawWe will share information about you if state or federal lawsrequire it, including with the Department of Health and HumanServices if it wants to see that we’re complying with federalprivacy law.Respond to organ and tissue donation requests We can share health information about you with organprocurement organizations. Work with a medical examiner or funeral directorWe can share health information with a coroner, medicalexaminer, or funeral director when an individual dies.Address workers’ compensation, law enforcement, and othergovernment requestsWe can use or share health information about you:For workers’ compensation claimsFor law enforcement purposes or with a law enforcement officialWith health oversight agencies for activities authorized by lawFor special government functions such as military, nationalsecurity, and presidential protective services Respond to lawsuits and legal actionsWe can share health information about you in response to acourt or administrative order, or in response to a subpoena. Treat youWe can use your health information and share it with otherprofessionals who are treating you.Example: A doctor treating you for an injury asks another doctorabout your overall health condition.฀฀ ฀

When it comes to your health information, youhave certain rights. This section explains your rights and some of ourresponsibilities to help you. Get an electronic or paper copy of your medical recordYou can ask to see or get an electronic or paper copy of yourmedical record and other health information we have about you.Ask us how to do this.We will provide a copy or a summary of your health information,usually within 30 days of your request. We may charge areasonable, cost-based fee.Ask us to correct your medical recordYou can ask us to correct health information about you that youthink is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writingwithin 60 days.Request confidential communicationsYou can ask us to contact you in a specific way (for example,home or office phone) or to send mail to a different address.We will say “yes” to all reasonable requests.Ask us to limit what we use or shareYou can ask us not to use or share certain health information fortreatment, payment, or our operations. We are not required toagree to your request, and we may say “no” if it would affect yourcare.If you pay for a service or health care item out-of-pocket in full,you can ask us not to share that information for the purpose ofpayment or our operations with your health insurer. We will say“yes” unless a law requires us to share that information.Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of the times we’ve shared yourhealth information for six years prior to the date you ask, who weshared it with, and why.We will include all the disclosures except for those abouttreatment, payment, and health care operations, and certainother disclosures (such as any you asked us to make). We’llprovide one accounting a year for free but will charge areasonable, cost-based fee if you ask for another one within 12months.Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even ifyou have agreed to receive the notice electronically. We willprovide you with a paper copy promptly.Choose someone to act for youIf you have given someone medical power of attorney or ifsomeone is your legal guardian, that person can exercise yourrights and make choices about your health information.We will make sure the person has this authority and can act foryou before we take any action.฀File a complaint if you feel your rights are violated฀ You can complain if you feel we have violated your rights bycontacting us using the information on the front panel and backpanel of this brochure. ฀You can file a complaint with the U.S. Department of Health andHuman Services Office for Civil Rights by sending a letter to 200Independence Avenue, S.W., Washington, D.C., 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.htmlWe will not retaliate against you for filing a complaint. For certain health information, you can tell us yourchoices about what we share. If you have a clearpreference for how we share your information in thesituations described below, talk to us. Tell us whatyou want us to do, and we will follow yourinstructions.In these cases, you have both the right and choice to tell usto:Share information with your family, close friends, orothers involved in your careShare information in a disaster relief situationInclude your information in a hospital directoryIf you are not able to tell us your preference, for example if youare unconscious, we may go ahead and share your informationif we believe it is in your best interest. We may also share yourinformation when needed to lessen a serious and imminentthreat to health or safety.In these cases we never share your information unless yougive us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notesIn the case of fundraising:We may contact you for fundraising efforts, but you cantell us not to contact you again.How do we typically use or share your healthinformation?We typically use or share your health information inthe following ways.Run our organization We can use and share your health information to run ourpractice, improve your care, and contact you when necessary. Example: We use health information about you to manage yourtreatment and services.Bill for your servicesWe can use and share your health information to bill and getpayment from health plans or other entities.Example: We give information about you to your health insuranceplan so it will pay for your services.฀ ฀฀ ฀How else can we use or share your health information? We are allowed or required to share your information in other ways– usually in ways that contribute to the public good, such as publichealth and research. We have to meet many conditions in the law before we can shareyour information for these purposes. For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlHelp with public health and safety issues We can share health information about you for certain situationssuch as:Preventing diseaseHelping with product recallsReporting adverse reactions to medicationsReporting suspected abuse, neglect, or domestic violencePreventing or reducing a serious threat to anyone’s health orsafetyDo researchWe can use or share your information for health researchComply with the lawWe will share information about you if state or federal lawsrequire it, including with the Department of Health and HumanServices if it wants to see that we’re complying with federalprivacy law.Respond to organ and tissue donation requests We can share health information about you with organprocurement organizations. Work with a medical examiner or funeral directorWe can share health information with a coroner, medicalexaminer, or funeral director when an individual dies.Address workers’ compensation, law enforcement, and othergovernment requestsWe can use or share health information about you:For workers’ compensation claimsFor law enforcement purposes or with a law enforcement officialWith health oversight agencies for activities authorized by lawFor special government functions such as military, nationalsecurity, and presidential protective services Respond to lawsuits and legal actionsWe can share health information about you in response to acourt or administrative order, or in response to a subpoena. Treat youWe can use your health information and share it with otherprofessionals who are treating you.Example: A doctor treating you for an injury asks another doctorabout your overall health condition.฀฀ ฀

When it comes to your health information, youhave certain rights. This section explains your rights and some of ourresponsibilities to help you. Get an electronic or paper copy of your medical recordYou can ask to see or get an electronic or paper copy of yourmedical record and other health information we have about you.Ask us how to do this.We will provide a copy or a summary of your health information,usually within 30 days of your request. We may charge areasonable, cost-based fee.Ask us to correct your medical recordYou can ask us to correct health information about you that youthink is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writingwithin 60 days.Request confidential communicationsYou can ask us to contact you in a specific way (for example,home or office phone) or to send mail to a different address.We will say “yes” to all reasonable requests.Ask us to limit what we use or shareYou can ask us not to use or share certain health information fortreatment, payment, or our operations. We are not required toagree to your request, and we may say “no” if it would affect yourcare.If you pay for a service or health care item out-of-pocket in full,you can ask us not to share that information for the purpose ofpayment or our operations with your health insurer. We will say“yes” unless a law requires us to share that information.Get a list of those with whom we’ve shared informationYou can ask for a list (accounting) of the times we’ve shared yourhealth information for six years prior to the date you ask, who weshared it with, and why.We will include all the disclosures except for those abouttreatment, payment, and health care operations, and certainother disclosures (such as any you asked us to make). We’llprovide one accounting a year for free but will charge areasonable, cost-based fee if you ask for another one within 12months.Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even ifyou have agreed to receive the notice electronically. We willprovide you with a paper copy promptly.Choose someone to act for youIf you have given someone medical power of attorney or ifsomeone is your legal guardian, that person can exercise yourrights and make choices about your health information.We will make sure the person has this authority and can act foryou before we take any action.฀File a complaint if you feel your rights are violated฀ You can complain if you feel we have violated your rights bycontacting us using the information on the front panel and backpanel of this brochure. ฀You can file a complaint with the U.S. Department of Health andHuman Services Office for Civil Rights by sending a letter to 200Independence Avenue, S.W., Washington, D.C., 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.htmlWe will not retaliate against you for filing a complaint. For certain health information, you can tell us yourchoices about what we share. If you have a clearpreference for how we share your information in thesituations described below, talk to us. Tell us whatyou want us to do, and we will follow yourinstructions.In these cases, you have both the right and choice to tell usto:Share information with your family, close friends, orothers involved in your careShare information in a disaster relief situationInclude your information in a hospital directoryIf you are not able to tell us your preference, for example if youare unconscious, we may go ahead and share your informationif we believe it is in your best interest. We may also share yourinformation when needed to lessen a serious and imminentthreat to health or safety.In these cases we never share your information unless yougive us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notesIn the case of fundraising:We may contact you for fundraising efforts, but you cantell us not to contact you again.How do we typically use or share your healthinformation?We typically use or share your health information inthe following ways.Run our organization We can use and share your health information to run ourpractice, improve your care, and contact you when necessary. Example: We use health information about you to manage yourtreatment and services.Bill for your servicesWe can use and share your health information to bill and getpayment from health plans or other entities.Example: We give information about you to your health insuranceplan so it will pay for your services.฀ ฀฀ ฀How else can we use or share your health information? We are allowed or required to share your information in other ways– usually in ways that contribute to the public good, such as publichealth and research. We have to meet many conditions in the law before we can shareyour information for these purposes. For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlHelp with public health and safety issues We can share health information about you for certain situationssuch as:Preventing diseaseHelping with product recallsReporting adverse reactions to medicationsReporting suspected abuse, neglect, or domestic violencePreventing or reducing a serious threat to anyone’s health orsafetyDo researchWe can use or share your information for health researchComply with the lawWe will share information about you if state or federal lawsrequire it, including with the Department of Health and HumanServices if it wants to see that we’re complying with federalprivacy law.Respond to organ and tissue donation requests We can share health information about you with organprocurement organizations. Work with a medical examiner or funeral directorWe can share health information with a coroner, medicalexaminer, or funeral director when an individual dies.Address workers’ compensation, law enforcement, and othergovernment requestsWe can use or share health information about you:For workers’ compensation claimsFor law enforcement purposes or with a law enforcement officialWith health oversight agencies for activities authorized by lawFor special government functions such as military, nationalsecurity, and presidential protective services Respond to lawsuits and legal actionsWe can share health information about you in response to acourt or administrative order, or in response to a subpoena. Treat youWe can use your health information and share it with otherprofessionals who are treating you.Example: A doctor treating you for an injury asks another doctorabout your overall health condition.฀฀ ฀

We are required by law to maintain the privacy andsecurity of your protected health information.We will let you know promptly if a breach occurs thatmay have compromised the privacy or security of yourinformation.We must follow the duties and privacy practicesdescribed in this notice and give you a copy of it.We will not use or share your information other than asdescribed here unless you tell us we can in writing. Ifyou tell us we can, you may change your mind at anytime. Let us know in writing if you change your mind.For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlThis notice describes how medicalinformation about you may be used anddisclosed and how you can get access tothis information. Please review it carefully.We can change the terms of this notice, and the changeswill apply to all information we have about you. The newnotice will be available upon request, in our office, and onour web site.This Notice of Privacy Practices applies to the followingorganization Krizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comDesigned by Krizia Baldon via CanvaWith information from Compliancy Group: Notice of Privacy PracticesApril 12, 2024 You have the right to:Get a copy of your paper or electronic medical recordCorrect your paper or electronic medical recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we’ve shared yourinformationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights havebeen violated➤ See inside left panel for more information on these rightsand how to exercise themYou have some choices in the way that we use and shareinformation as we:Tell family and friends about your condition ฀ Provide disaster reliefInclude you in a hospital directoryProvide mental health careMarket our services and sell your informationRaise funds➤ See inside middle panel for more information on thesechoices and how to exercise themWe may use and share information as we:Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo researchComply with the lawRespond to organ and tissue donation requestsWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, andother government requestsRespond to lawsuits and legal actions➤ See inside middle and right panels for more informationon these choices and how to exercise themKrizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comChanges to the Terms of this Notice

We are required by law to maintain the privacy andsecurity of your protected health information.We will let you know promptly if a breach occurs thatmay have compromised the privacy or security of yourinformation.We must follow the duties and privacy practicesdescribed in this notice and give you a copy of it.We will not use or share your information other than asdescribed here unless you tell us we can in writing. Ifyou tell us we can, you may change your mind at anytime. Let us know in writing if you change your mind.For more information see:https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.htmlThis notice describes how medicalinformation about you may be used anddisclosed and how you can get access tothis information. Please review it carefully.We can change the terms of this notice, and the changeswill apply to all information we have about you. The newnotice will be available upon request, in our office, and onour web site.This Notice of Privacy Practices applies to the followingorganization Krizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comDesigned by Krizia Baldon via CanvaWith information from Compliancy Group: Notice of Privacy PracticesApril 12, 2024 You have the right to:Get a copy of your paper or electronic medical recordCorrect your paper or electronic medical recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we’ve shared yourinformationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights havebeen violated➤ See inside left panel for more information on these rightsand how to exercise themYou have some choices in the way that we use and shareinformation as we:Tell family and friends about your condition ฀ Provide disaster reliefInclude you in a hospital directoryProvide mental health careMarket our services and sell your informationRaise funds➤ See inside middle panel for more information on thesechoices and how to exercise themWe may use and share information as we:Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo researchComply with the lawRespond to organ and tissue donation requestsWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, andother government requestsRespond to lawsuits and legal actions➤ See inside middle and right panels for more informationon these choices and how to exercise themKrizia Baldon, Privacy Officer200 N. Vineyard Blvd. Suite A325-5146. Honolulu, HI 96817 Ph: 808.900.2648 | Fax: 808.748.0945Email: kbaldon@islandabaoahu.com www.islandabaoahu.comChanges to the Terms of this Notice