Testing

I hereby authorize the release of medical information, including complete medical records, test results, and billing information to my insurance company, and to the other medical professionals and medical care institutions, that I may be referred to for treatment.

I understand this information will be used to review investigate, or make payment of a claim, and review records for quality improvement initiative, audit compliance, utilization management, and complaint resolution.

I authorized direct payment to Hawaii Heart Associates for all medical or surgical benefits otherwise payable to me under terms of my insurance. I understand I am financially responsible for all co-payments, co-insurance, deductibles, and non-covered services.

I agreed to pay legal interest, collection expenses and attorneys’ fees incurred to collect the amount I may owe.

I understand that in Hawaii, a general excise tax applies to medical services provided by group and private practice physicians, and I will be responsible for paying this fee.

A photocopy of this authorization shall be considered as effective and valid as the original.

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of the office that are involved in your care, for the purpose of providing healthcare services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your healthcare with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you; or your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations

We may use or disclose, asneeded, your protected health information in order to support our practice’s activities, training of medical students, and licensing. For example, we may disclose your protected health information to medical school students that see patients at our office. In our day-to-day practice activities, we may use a sign-in sheet at the registration desk, we may also call you by name in the waiting room when your physician is ready to see you. Your protected health information may also be used to contact you to remind you of an appointment.

Disclosure of Protected Health Information

Hawaii Heart Associates may make disclosures of your protected health information to or regarding the following when required by law.Your Rights to Privacy Your medical information will not be shared and/or disclosed to anyone without your permission except asdescribed in this notice or required by law. You may, in writing, revoke this authorization at any time. You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

You have the right to inspect and copy your protected health information. If you request a copy of the information, we may charge a reasonable fee for the cost of copying, mailing or other supplies associated with your request. Under federal law, however, you may not inspect or copy psychotherapy notes; information completed in reasonable anticipation of, or use in a civil criminal, or administrated action or proceeding, and protected health information that is subject to law that prohibits health information. You also have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information, as well as extra copies of this notice.

You have the right to request a restriction or an amendment of your protected health information. This means that you ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restrictions requested and to whom you want the restriction to apply. Please note, your physician is not required to agree to a restriction or amendment that you may request if they believe it is in your best interest. You then have the right to use another healthcare professional or file statement of disagreement with us.

Complaint

You may complain to us or to the Secretary of Health and Human Services if you have concerns about your privacy. We will not retaliate against you for filing a complaint. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. This notice became effective April 14, 2003.