Kuakini Health System
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Kuakini Health System and its subsidiaries (Kuakini Medical Center, Kuakini Geriatric Care, Inc., Kuakini Support Services, Inc., and Kuakini Foundation) are committed to protecting the privacy and confidentiality of the personal health information of its patients, residents, and clients. Kuakini recognizes the importance of safeguarding such information that can identify or be used to identify an individual, therefore we will take every reasonable step to provide the proper protections and security. This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This Notice describes how Kuakini Health System and its subsidiaries may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights to access and control your PHI under certain conditions.
Your protected health information (PHI) means any information of you, whether in any form or medium of oral, written, or electronic communications, including demographic information, that (1) is created or received by your health care provider(s), and (2) relates to your past, present or future physical or mental health or condition or to the provision of health care services to you or to the past, present, or future payment for the provision of health care services to you.
Kuakini Health System and its subsidiaries are committed to following the HIPAA law and regulations. Except as described in this Notice or as permitted under applicable federal and state law, Kuakini will not use or disclose your PHI without your written authorization. Kuakini reserves the right to change its practices and the terms of this Notice and to make the new Notice provisions effective for all PHI that Kuakini maintains. If we change this Notice, we will provide you with a copy of the revised Notice, upon your request via regular mail or in-person contact.
I. Uses and Disclosures of Protected Health Information (PHI) Permitted Without Authorization
Kuakini Health System and its subsidiaries may use your protected health information (PHI) for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your PHI may be used or disclosed only for these purposes unless Kuakini has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulations or by applicable federal and state law. Disclosures of your PHI for the purposes described in this Notice may be made orally, in writing, or by electronic communications including facsimile, and secured network connections. Kuakini contracts with a number of business associates for the purchase of services and to assist Kuakini in providing treatment, payment, and health care operations. For these business associates, Kuakini may disclose your PHI to the extent necessary for the business associates to perform their jobs and functions as contracted and requested by Kuakini. To protect your PHI, Kuakini requires the business associates to appropriately safeguard the PHI disclosed to them.
A. Treatment. Kuakini will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose your PHI to the physicians and other health care professionals who may be treating you or the consultants and health care professionals who may be working with your physician(s) with respect to your care. The physicians in the organized medical staff of Kuakini Medical Center and the physicians with privileges at Kuakini Geriatric Care, Inc. facilities are designated as part of an Organized Health Care Arrangement (OHCA) with Kuakini. In some cases, we may also disclose your PHI to an outside health care provider for purposes of the treatment activities you will or may have received by the other provider.
B. Payment. Kuakini will use and disclose your PHI, as necessary, to obtain payment for the health care services that we provide to you. This may include certain communications to your health insurer to get approval for the treatment that we will provide based on the specific orders of your physician(s) and other health care providers. For example, if a hospital admission is ordered by your physician, we may need to disclose information to your health insurer to get prior approval for your hospitalization. We may also disclose your PHI to your health insurer to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for your services, we may also need to disclose your PHI to your health insurer to demonstrate the medical necessity of the services or, as required by your health plan, for utilization review purposes. We may also disclose your PHI to another health care provider involved in your care for the other health care provider’s payment activities.
C. Health Care Operations. Kuakini will use or disclose your PHI, as necessary, for purposes of Kuakini’s health care operations in order to facilitate the functions and activities of the Health System and its subsidiaries and to provide quality care to all patients/residents/clients and maintain patient/resident/client safety. Kuakini’s health care operations include such activities as:
1 Quality assessment and improvement activities.
2 Employee evaluation activities.
3 Professional review activities.
4 Training programs including those in which students, trainees, medical residents, or practitioners in health care learn under supervision.
5 Accreditation, certification, licensing or credentialing activities.
6 Review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs.
7 Business management and general administrative activities.
In certain situations, we may also disclose your PHI to another health care provider or health plan for their health care operations.
D. Other Uses and Disclosures. As part of treatment, payment and healthcare operations, Kuakini may also use or disclose your PHI for the following purposes:
1 To remind you of an appointment for health care services.
2 To inform you of potential treatment alternatives or options, and other health information.
3 To inform you of health-related benefits or services that may be of interest to you.
4 To contact you for fundraising purposes for Kuakini Health System and its subsidiaries that includes Kuakini Foundation, a 501(c)(3) charitable organization. If you do not wish to be contacted for fundraising for Kuakini, please contact Kuakini’s Privacy Officer to opt-out of direct fundraising contact.
E. Incidental Disclosures. Kuakini may disclose your PHI incidental to ourprovision of treatment, payment, or health care operations. Some examples include conversations with you regarding your health care or with your health care professionals in a semi-private patient room, and your PHI that is maintained for the access by your physicians and other authorized personnel and users in the work areas of the Kuakini facilities.
F. Minors. In most situations, a parent or guardian has the right to act as the personal representative of their minor children. However, in some circumstances, state laws treat minors as adults with respect to health care services. Kuakini will follow applicable state laws regarding disclosure of a minor’s PHI.
- Uses and Disclosures Beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules permit Kuakini to use or disclose your protected health information (PHI) without your authorization or permission for a number of reasons including the following:
A. When Legally Required. Kuakini will disclose your protected health information when we are required to do so by any federal, state or local law.
B. When There Are Risks to Public Health. Kuakini may disclose your PHI for the following public health purposes and activities:
1 To disclose PHI to public health or government authorities in order to prevent, control, or report disease, injury or disability as permitted by law.
2 To report vital statistics and events such as birth or death as permitted or required by law.
3 To disclose PHI to conduct public health surveillance, investigations, and interventions as permitted or required by law.
4 To disclose PHI and report adverse events and product defects to the Food and Drug Administration (FDA), to track FDA regulated products, to enable product recalls, repairs or replacements, and to conduct post marketing surveillance.
5 To notify an individual who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
6 To report to an employer information about an individual who is a member of the workforce as legally permitted or required.
C. To Report Abuse, Neglect or Domestic Violence. Kuakini may notify government authorities if we believe that a patient/resident/client is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient/resident/client agrees to the disclosure. Also the disclosure by Kuakini will be based on our belief that it is necessary to prevent serious harm to you or another person, or that the law enforcement or government authority that is to receive the report represents that it is necessary and will not be used against you.
D. To Conduct Health Oversight Activities. Kuakini may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; compliance with civil rights laws; or other activities necessary for conducting appropriate oversight as authorized by law. We will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care services or public benefits.
E. For Judicial and Administrative Proceedings. Kuakini may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request, or other lawful process in some circumstances. If the legal request for your PHI is from another person involved in a dispute with you, Kuakini will make every reasonable effort to inform you about the request or to obtain an order regarding the release of the requested PHI.
F. For Law Enforcement Purposes. Kuakini may disclose your PHI to a law enforcement official for law enforcement purposes as follows:
1 As required by law for reporting of certain types of wounds or other physical injuries.
2 Pursuant to a court order, court-ordered warrant, subpoena, summons or similar process.
3 For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
4 Under certain limited circumstances, when you are the victim of a crime.
5 For the purpose of reporting to a law enforcement official if Kuakini has a suspicion that your death was the result of criminal conduct.
6 In an emergency in order to report a crime.
G. To Coroners, Medical Examiners, and Funeral Directors. We may disclose your PHI to a coroner or medical examiner for identification purposes, to determine cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose your PHI in reasonable anticipation of your death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
H. To Organ or Tissue Procurement Organizations. Kuakini may disclose your PHI to organ or tissue procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant as provided by law.
I. For Research Purposes. Kuakini may use or disclose your PHI for research purposes when the use or disclosure for research has been either waived of the authorization requirements according to established criteria or approved with authorization requirements by Kuakini’s Institutional Review Board (IRB) or by a privacy board if designated by Kuakini, whereby the IRB or privacy board has reviewed the research proposal and research protocols to address the privacy of your PHI.
J. To Avert a Serious Threat to Health or Safety. Kuakini may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public or another person.
K. To Correctional Institutions. If you are, or become, an inmate of a correctional institution, Kuakini may disclose your PHI to the institution or its agents when necessary for your health care and the health and safety of others.
L. For Specified Government Functions. In certain circumstances, federal law and regulations authorize a health care provider such as Kuakini to use or disclose your PHI for the following purposes.
1 To facilitate specified government functions relating to military and veterans activities whereby if you are a member of the armed forces, Kuakini may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authorities.
2 To facilitate national security and intelligence activities, Kuakini may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
3 To facilitate protective services for the President of the United States of America and others, Kuakini may release your PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations.
4 To facilitate medical suitability determinations, Kuakini may release your PHI to authorized federal agencies and officials.
5 To facilitate law enforcement custodial situations, Kuakini may release your PHI to law enforcement officials.
M. For Worker's Compensation. Kuakini may release your PHI to the extent authorized by and to the extent necessary to comply with the laws related to worker's compensation or other similar programs.
- Uses and Disclosures Permitted Without Authorization But With Opportunity to Object
Kuakini may disclose your protected health information (PHI) to your family member, other relative, or a close personal friend or any person that you expressly or implicitly authorize to have access to your PHI if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.
You have the right to object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for Kuakini to make the disclosure of your PHI to a specific person, and the disclosure is directly relevant to that person’s involvement with your care, we may disclose your PHI as described.
IV. Uses and Disclosures Requiring Your Authorization
Other than as stated above (or as otherwise permitted or required by law), Kuakini will not use or disclose your protected health information (PHI) unless we receive your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization. Upon receipt or the written revocation, Kuakini will stop using or disclosing your PHI.
V. Your Rights With Respect To Your Protected Health Information (Individual Privacy Rights)
You have the following rights regarding your protected health information (PHI).
A. Right to Inspect and Obtain a Copy of Your Protected Health Information. You may inspect and obtain a copy of your PHI that is contained in a “designated record set” for as long as Kuakini maintains the PHI. A “designated record set” generally contains the patient’s/resident’s/client’s medical records and billing records and any other records that your physician(s), other health care professionals, and Kuakini as the health care provider uses for making decisions about your health care, relating to payment for services rendered, and supporting the health care operations of Kuakini.
Under applicable federal laws, however, you may not inspect or receive a copy of the following PHI and related records: (1) psychotherapy notes; (2) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and (3) PHI that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access to the PHI reviewed.
Kuakini may deny your request to inspect or receive a copy of your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You do have the right to request a review of this decision to deny access to the PHI.
To inspect or receive a copy of your PHI, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Notice. If you request a copy of your PHI, Kuakini may charge you a fee for the costs of copying, mailing or other supplies and costs that are incurred in complying with your request.
Please contact the Privacy Officer if you have questions about access to your PHI.
B. Right to Request a Restriction on Uses and Disclosures of Your Protected Health Information. You may request Kuakini not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. You may also request that Kuakini not disclose your PHI to family members or friends who may be involved in your health care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Kuakini is not required to agree to any restriction that you may request. We will notify you if we deny your request to a restriction. If Kuakini does agree to your requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, Kuakini may terminate its agreement to a restriction. You may request a restriction by contacting the Admission Department, Medical Social Work Department, Patient Relations Representative, Kuakini Administration Office, or the Privacy Officer.
C. Right to Request to Receive Confidential Communications From Kuakini by Alternative Means or at an Alternative Location. You may request that Kuakini use confidential means to communicate with you in certain ways to protect your privacy. Kuakini will accommodate all reasonable requests. We may condition the accommodation of your request by asking you for information as to how your payment will be handled and/or specification of an alternative mailing address or other method of contact. We will not require you to provide an explanation for your request. Your request must be made in writing to the Privacy Officer.
D. Right to Amend Your Protected Health Information. If you feel that your PHI maintained by Kuakini is incomplete or incorrect, you may request an amendment of your PHI in a “designated record set” for as long as Kuakini maintains the PHI. Kuakini reserves the right to record any amendments of your PHI in a specified section or file of a “designated record set” that contains your PHI. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision. Kuakini may prepare a rebuttal to your statement and we will provide you with a copy of any such rebuttal. Your request for amending your PHI must be in writing and must be directed to the Privacy Officer. In the written request for amendment of your PHI, you must provide a reason to support your request for amendment.
E. Right to Receive an Accounting of Certain Disclosures of Protected Health Information. You may request an accounting of certain disclosures of your PHI made by Kuakini. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. Also the accounting of disclosures exclude the disclosures made directly to you, disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, disclosures to friends or family members involved in your care, incidental disclosures permitted by law, disclosures made for notification purposes, or certain other disclosures that the health care provider is permitted to make without your authorization. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. The request must specify the time period sought for the accounting, but the time period may not exceed six (6) years. Kuakini is not required to provide an accounting of disclosures that have taken place prior to April 14, 2003. The right to receive an accounting of disclosures is subject to certain other exceptions. Kuakini may charge you for the cost of providing the accounting of disclosures. We will notify you of the cost involved in your request and you have the right to withdraw or modify your request at that time.
F. Right to Obtain a Paper Copy of This Notice. Upon request, we will provide a separate paper copy of this Notice of Privacy Practices to you even if you have already received a copy of the notice or have agreed to accept this notice electronically. To obtain a paper copy of this Notice, contact the Admissions Department (at 808-547-9789), Medical Social Work Department (at 808-547-9189), Patient Relations Representative (at 808-547-9791), or Kuakini Administration Office (at 808-547-9231).
VI. Kuakini’s Duties as Health Care Provider
Kuakini is required by law to maintain the privacy of your protected health information (PHI) and to provide you with this Notice of Privacy Practices that describe Kuakini’s duties and practices relating to a patient’s/resident’s/client’s personal health information. We are required by law to abide by terms of this Notice as may be amended from time to time. Kuakini reserves the right to change its practices and the terms of this Notice and to make the new Notice provisions effective for all PHI that Kuakini maintains. If we change this Notice, we will provide you with a copy of the revised Notice, upon your request via regular mail or through in-person contact.
VII. Applicable State Laws
Some of the provisions and restrictions described in this Notice may be limited in certain cases by applicable state laws that may be more stringent than the federal standards. Kuakini is committed to comply with all applicable state laws.
VII. Complaints Regarding Your Privacy and Rights
If you believe your privacy rights have been violated, you have the right to file a complaint to Kuakini, c/o the Privacy Officer, or to the Department of Health and Human Services (DHHS) Office for Civil Rights. You may file your complaint in writing using the contact information below. We encourage you to notify us of any concerns you may have regarding the privacy of your PHI or your privacy rights. There will be no retaliation against you in any way for filing a complaint with Kuakini.
VIII. How to Get More Information and Contact Office
If you have questions or would like additional information about Kuakini’s privacy practices and your rights under the federal privacy regulations, you may contact the Privacy Officer. The Privacy Officer can be contacted by telephone at 808-547-9231 or by fax at 808-547-9547. The mailing address for the Privacy Officer is as follows:
Attention: Privacy Officer
c/o Administration Office
Kuakini Health System
347 N. Kuakini Street
Honolulu, Hawaii 96817
IX. Effective Date of Notice
This Notice of Privacy Practices is effective as of April 14, 2003.