We are required by law to:
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Make sure that health and service information that identifies you is kept private; and
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Give you this notice of our legal duties and privacy practices.
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People Involved in Your Care. If you choose to have a friend or family member involved in your care, we may give that person health information about you. If you donÕt want this person to receive health information about you, please let us know.
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Research. At times, we may use and disclose health and service information about you for approved research purposes. All research projects must be approved by our Board of Directors. We will take steps to make sure your privacy is protected.
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As Required By Law. We will disclose health and service information about you when we are required to do so by federal, state or local law.
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To Avert a Serious Threat to Health or Safety. We may use and disclose health and service information about you when it is necessary to prevent a serious threat to the health and safety of you or anybody else.
SPECIAL SITUATIONS
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Military and Veterans. If you are a member of the armed forces, we may release health and service information about you as required by military command authorities.
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Public Health Risks. We may disclose health and service information about you for public health activities. These activities generally include the following:
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To report child abuse or neglect;
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To notify a person who may have been exposed to a disease or may be at risk for getting or spreading a disease; and
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To notify the appropriate government authority if we believe a client 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.
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Oversight Activities. We may disclose health and service information to a health oversight agency for activities authorized by law. Oversight activities may include audits, investigations, inspections, credentialing and licensure.
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Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health and service information about you in response to a court or administrative order, 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 get an order protecting the information requested.
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Law Enforcement. We may release health and service information if asked to do so by a law enforcement official:
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In response to a court order, subpoena, warrant, summons or similar process;
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To identify or locate a suspect, fugitive, material witness, or missing person;
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About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
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About a death we believe may be the result of criminal conduct;
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About criminal conduct at PACT;
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In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime; and
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For national security as authorized by law.
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Inmates. If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may release health and service information about you to the correctional facility or law enforcement official.
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Assist in Official Duties. We may use and disclose health and service information about you to assist coroners, medical examiners or funeral directors with their official duties.
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WorkersÕ Compensation. We may use and disclose health and service information about you for workersÕ compensation purposes, as permitted by law.
OTHER USES OF HEALTH AND SERVICE INFORMATION.
Other uses and disclosures of health and service information not covered by this notice or the laws that apply to us will be made only with your written permission. If you give us permission to use or disclose health and service 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 and service 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. You may not be able to revoke an authorization which you signed as a condition of obtaining insurance coverage.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health and service information we have about you:
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Right to Inspect and Copy. You have the right to inspect and copy health and service information about you with some limited exceptions. To arrange for access to your records or to receive a copy of your records, you must send a request in writing to: Parents And Children Together / Attn: Privacy Officer, 1485 Linapuni Street, Suite 105, Honolulu HI 96819.
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We may charge a fee for the costs of copying and mailing your request.
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We may deny your request in certain very limited situations. If we do, we will inform you of the reason your request was denied. In most situations, you will be able to request that the denial be reviewed.
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Right to Amend. If you think that the health and service information we have about you is wrong or incomplete, you may ask us to correct or add information. You have the right to request an amendment for as long as the information is kept by or for PACT.
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To request an amendment, your request must be made in writing and sent to Parents And Children Together / Attn: Privacy Officer, 1485 Linapuni Street, Suite 105, Honolulu HI 96819.
You must give the reason for your request. If your request is approved, we will make the change. If your request is denied, we will tell you why and how you can file a statement of disagreement.
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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 change information that was not created by us or information that is accurate and complete.
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Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of health and service information about you but does NOT include disclosures for treatment, payment or operations; disclosures made to you, persons involved in your care, law enforcement officials or correctional institutions; disclosures for national security or intelligence purposes; disclosures for which you have signed an authorization; or any disclosures made before April 14, 2003.
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To request this list of disclosures, you must send your request in writing to: Parents And Children Together; Attn: Privacy Officer; 1485 Linapuni Street, Suite 105; Honolulu HI 96819. You must indicate the time period of the disclosures you are requesting which may not include dates before April 14, 2003. Your request will be free of charge if you have not received a list of disclosures for the preceding 12-month period. Otherwise, we may charge you for the cost of providing you with the list of disclosures.
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Right to Request Restrictions. You have the right to request a restriction or limitation on the health and service information we use or disclose about you for treatment, payment or health care operations or notification purposes. We are not required to agree to your request. Our policy is not to agree with restrictions if the information is necessary for treatment, payment and operations. If we do agree, we will abide by that restriction except if the restricted information is needed to provide you with emergency treatment.
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Right to Request Confidential Communications. You have the right to request that we communicate with you about health and service 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.
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To request confidential communications, make your request in writing to Parents And Children Together; Attn: Privacy Officer; 1485 Linapuni Street, Suite 105; Honolulu HI 96819. Your request must state how or where you wish to be contacted.
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Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice upon your request.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health and service information we already have about you as well as any information we will have about you in the future. A copy of the most current notice will be posted in all PACT program offices. A copy of the notice will be mailed to you upon your request.
COMPLAINTS
If you think your privacy rights have been violated, you may file a written complaint with PACT or with the Secretary of the Department of Health and Human Services.
To file a complaint with PACT, contact: Privacy Officer / Parents And Children Together, 1485 Linapuni Street, Suite 105, Honolulu HI 96819.
To file a complaint with the Secretary of Department of Health and Human Services contact: Director of the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue S.W. – Room 506-F, Washington, D.C. 20201.
Parents And Children Together
Acknowledgement of Notice of Privacy Practices
I acknowledge that PACT has given me a copy of the PACTÕs Notice of Privacy Practices. Signing this form only means that I have received the Notice of Privacy Practices. Signing or not signing this form will not affect the services I receive from PACT.
Date Signature
Printed Name
Acknowledgement is for me and/or the following minors receiving services:
To be completed by PACT staff if client signature can not be obtained:
Good faith efforts were made to obtain a signature from the client to acknowledge receipt of PACTÕs Notice of Privacy Practices. The reason the client signature could not be obtained is:
( ) Client refused to sign after being requested to do so.
( ) Other: (please describe) ____________________________________
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Signature of Staff Member Date
This form was interpreted for me at my request. £ Yes
