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THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU/YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures: Hale Kipa, Inc. will use and disclose elements of you/your child’s protected health information (PHI) in the following ways without your signed authorization:

• Release of information to your health care provider to obtain payment.
• Continuation of care by a specialist or doctor.
• When release is required by law, including in judicial settings and to health oversight regulatory agencies and law enforcement.
• In emergency situations or to avert serious health/safety situations.
• To contact you and/or your parent/legal guardian about appointment reminders, treatment alternatives, and other health related benefits and services.
• When there is clear and imminent danger to you, your child, another individual or to society, and then only to appropriate professional workers, public authorities, and/or family member who could assist in providing protection.
• To medical examiners, coroners or funeral directors to aid in identifying your child or to help them in performing their duties.
• Between and among Hale Kipa staff, contractors and volunteers, case materials may be disclosed on a need-to-know basis.
• During internal quality assurance/improvement reviews.

Your rights: You have the following rights concerning your PHI:

• To request restrictions on certain uses and disclosures of PHI, however Hale Kipa, Inc. is not required to agree to a restriction you request.
• To inspect your client file(s) or your child’s client file.
• To request an amendment of PHI for as long as the PHI is maintained in the record. Hale Kipa, Inc. may deny your request.
• To request an accounting of disclosures of your PHI.
• To receive correspondence of confidential information by alternative means or location.
• To get updates or reissues of this notice, at your request.
• To complain to Hale Kipa, Inc. or the U.S. Department of Health and Human Services if you feel your privacy rights have been violated.

How you can inspect and/or amend your client file:

• Submit a written request to the Program Director stating the purpose for the request and specific information requested. Hale Kipa, Inc. may deny your request.
• Upon review of the file, or at anytime, you may insert an addition, correction, amendment or statement about your problem, our service or anything you want into the file – you may not erase, alter or destroy the original file(s).

Our duties: Hale Kipa, Inc. is required by law to maintain the privacy of you/your child’s PHI. We must abide by the terms of this notice or any update of this notice.

Effective date: This notice is effective April 14, 2003.