Kauai Osteopathic Patient Forms and Privacy Notice

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Lisa R. Chun, D.O.

Patient Information Form:

Click the link above to view the Patient Information Form. You may also print a copy of the form, fill it out and bring it with you to your appointment with Dr. Chun.

Patient Consent Form:

A signed Patient Consent form is needed prior to treatment.

HIPAA Privacy Notice:

As of April 14, 2003, new government regulations are in force regarding certain patient rights and how they can be exercised. It is recommended that you view Kaua`i Osteopathic, Inc.'s Privacy Notice. Please bring a signed Patient Consent Form with you to your appointment. Please note that because of the above ruling no sensitive information will be discussed or sent electronically.

The HIPPA regulations include certain patient rights and how they can be exercised. They include:

Right to information about covered entities privacy practices(hospital, facility, provider)-the notice must be written in plain language and include: the individual's right with respect to protect health information; the uses and disclosure of the information; the covered entities duties; how an individual can file a complaint and contact person at the entity. Specific requirements regarding how, when, and under what circumstances group health plans and HMO's must provide notice to patients are included in the regulations.

Right to review and copy health information that is used to make decisions about the patient-there are limited exceptions, such as psychotherapy notes and information for use in a civil, criminal, or administrative proceeding.

Right to amend information-patients may request that a health care provider amend their health information. This request may be denied if the information is accurate and complete or was not created by the covered entity. The entity must tell patients about their option for restricting disclosure of the disputed information.

Right to an accounting of disclosures-patients may receive an account of disclosures that a covered entity has made for purposes other than treatment, payment and health care operations for the six years previous to the request. There are some limited exceptions to the information that must be disclosed. The account must include a statement as to why the information was disclosed and who received it.

Right to request restriction of uses and disclosures-patients may request restriction on the use and disclose of their health information. Although not required to agree to the requests, the entity must document any restriction it agrees to and follow these restrictions.

Please note that because of the above ruling no sensitive information will be discussed or sent via email.