for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while
awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of
Court. In civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in
cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary
for the proper administration of justice.” In criminal cases, Hawaii has no statute granting therapist-patient privilege,
although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an
evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: Under state law, if I am engaged in my professional duties and you communicate to
me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person,
and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to
take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or
guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization.
By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate,
serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to
provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or a law enforcement
officer, whether you are a minor or an adult.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your
relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only
with your written permission. [This sentence is now required under the HIPAA “Final Rule.”]
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected
health information about you. You also have the right to request a limit on the medical information I disclose about you
to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another
party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you
request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to
limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right
to request and receive confidential communications of PHI by alternative means and at alternative locations. (For
example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills
to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To
request alternative communication, you must make your request in writing, specifying how or where you wish to be
· Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for
which you have neither provided consent nor authorization (as described in section III of this Notice). On your written
request, I will discuss with you the details of the accounting process
. · Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To
do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of
copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you
access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal,
or administrative proceeding.
· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask
me to amend the information. To request an amendment, your request must be made in writing, and submitted dot me.
In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend
information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the