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Notice of privacy practices

Maui Health System, a Kaiser Foundation Hospitals, Limited Liability Company (LLC)



In this notice we use the terms "we," "us," and "our" to describe the Maui Health System. For more details, please refer to section IV of this notice.


Your protected health information (PHI) is individually identifiable health information, including demographic information, about your past, present or future physical or mental health or condition, healthcare services you receive, and past, present or future payment for your healthcare. Demographic information means information such as your name, Social Security number, address, and date of birth.

PHI may be in oral, written, or electronic form. Examples of PHI include your medical record, billing records, and communications between you and your healthcare provider about your care. Your individually identifiable health information ceases to be PHI 50 years after your death.

If you are a Maui Health System patient and also an employee of any Kaiser Permanente organization, PHI does not include the health information in your employment records.


By law, we must

  1. protect the privacy of your PHI;
  2. tell you about your rights and our legal duties with respect to your PHI;
  3. notify you if there is a breach of your unsecured PHI; and
  4. tell you about our privacy practices and follow our notice currently in effect.

We take these responsibilities seriously and have put in place administrative safeguards (such as security awareness training and policies and procedures), technical safeguards (such as encryption and passwords), and physical safeguards (such as locked areas and requiring badges) to protect your PHI and, as in the past, we will continue to take appropriate steps to safeguard the privacy of your PHI.


This section tells you about your rights regarding your PHI, and describes how you can exercise these rights.

Your right to access and amend your PHI

Subject to certain exceptions, you have the right to view or get a copy of your PHI that we maintain in records relating to your care or decisions about your care or payment for your care. Requests must be in writing. After we receive your written request, we will let you know when and how you can see or obtain a copy of your record. If you agree, we will give you a summary or explanation of your PHI instead of providing copies. We may charge you a fee for the copies, summary or explanation.

If we do not have the record you asked for but we know who does, we will tell you who to contact to request it. In limited situations, we may deny some or all of your request to see or receive copies of your records, but if we do, we will tell you why in writing and explain your right, if any, to have our denial reviewed.

If you believe there is a mistake in your PHI or that important information is missing, you may request that we correct or add to the record. Requests must be in writing, tell us what corrections or additions you are requesting, and why the corrections or additions should be made. We will respond in writing after receiving your request. If we approve your request, we will make the correction or addition to your PHI. If we deny your request, we will tell you why and explain your right to file a written statement of disagreement.

Submit all written requests for access or amendments to the Maui Health System facility holding the records.

Maui Memorial Medical Center

Health Information Mgt.
221 Mahalani Street
Wailuku, HI 96793

Kula Hospital

Health Information Mgt.
100 Keokea Place
Kula, HI 96790

Lanai Community Hospital

628 7th Street
Lanai City, HI 96763

Your right to choose how we send PHI to you or someone else

You may ask us to send your PHI to you at a different address (for example, your work address) or by different means (for example, fax instead of regular mail).

If your PHI is stored electronically, you may request a copy of the records in an electronic format offered by the facility. You may also make a specific written request that we transmit the electronic copy to a designated third party.

If the cost of meeting your request involves more than a reasonable additional amount, we are permitted to charge you our costs that exceed that amount.

Your right to an accounting of disclosures of PHI

You may ask us for a list of our disclosures of your PHI. To obtain an accounting, please contact the Health Information Management department at Maui Memorial Medical Center, 221 Mahalani Street, Wailuku, Hawaii 96793. You are entitled to one disclosure accounting in any 12-month period at no charge. If you request any additional accountings less than 12 months later, we may charge a fee.

An accounting does not include certain disclosures, for example, disclosures:

  • to carry out treatment, payment, and healthcare operations;
  • for which we had a signed authorization;
  • of your PHI to you;
  • from a facility directory;
  • for notifications for disaster relief purposes;
  • to persons involved in your care and persons acting on your behalf; or
  • not covered by the right to an accounting.

Your right to request limits on uses and disclosures of your PHI

You may request that we limit our uses and disclosures of your PHI for treatment, payment, and healthcare operations purposes. We will review and consider your request. You may write to the MHS Compliance Officer at Maui Memorial Medical Center, 221 Mahalani Street, Wailuku, Hawaii 96793 for consideration of your request.

We are not required to agree to your request, except to the extent that you request a restriction on disclosures to a health plan or insurer for payment or healthcare operations purposes and the items or services have been paid for out of pocket in full. However, we can still disclose the information to a health plan or insurer for the purpose of treating you. For requests to restrict your PHI for payment or healthcare operations purposes, please request the restriction prior to receiving services at the facility, clinic, or medical office where you receive your care.

If the services are not paid for in full and out of pocket by you or by someone on your behalf, we do not have to agree to your request to restrict uses or disclosures of PHI for healthcare operations, payment, or treatment purposes. We will consider all submitted requests and, if we deny your request, we will notify you in writing.

Your right to receive a paper copy of this notice

You have a right to receive a paper copy of this notice upon request.


This notice applies to the Maui Health System, which includes:

  • Maui Memorial Medical Center
  • Maui Memorial Medical Center Outpatient Clinic
  • Kula Hospital
  • Kula Clinic
  • Lanai Community Hospital
  • Pacific Permanente Group LLC
  • Independent providers who are providing healthcare services at our facilities as part of the facility's medical staff

Our healthcare delivery sites include medical offices, clinics, hospitals and ambulatory surgery centers, any other licensed facilities of MHS in the region, appointment centers, and our website and mobile applications.

To provide you with the healthcare you expect, to treat you, to obtain payment for your care and to conduct our operations, such as quality assurance, accreditation, licensing, and compliance, these MHS companies share your PHI with each other.

Our personnel may have access to your PHI either as employees, physicians, professional staff members of our facilities, other authorized workforce members who may need access to PHI, including volunteers, residents, medical students, students of other healthcare professions or educational programs at our facilities, or persons working with us in other capacities.


Your confidentiality is important to us. Our physicians and employees are required to maintain the confidentiality of the PHI of our patients, and we have policies and procedures and other safeguards to help protect your PHI from improper use and disclosure. Sometimes we are allowed by law to use and disclose certain PHI without your written permission. We briefly describe these uses and disclosures below and give you some examples.

How much PHI is used or disclosed without your written permission will vary depending, for example, on the intended purpose of the use or disclosure. Sometimes we may only need to use or disclose a limited amount of PHI, such as to send you an appointment reminder or to confirm your identity. At other times, we may need to use or disclose more PHI, such as when we are providing medical treatment.

  • Treatment: This is the most important use and disclosure of your PHI. For example, our physicians, nurses, and other healthcare personnel, including trainees, involved in your care, use and disclose your PHI to diagnose your condition and evaluate your healthcare needs. Our personnel will use and disclose your PHI in order to provide and coordinate the care and services you need: for example, prescriptions, X-rays, and lab work. If you need care from healthcare providers who are not part of Maui Health System, such as Kaiser Permanente or community resources to assist with your healthcare needs at home, we may disclose your PHI to them.
  • Payment: Your PHI may be needed to permit us to bill and collect payment for treatment and health-related services that you receive. For example, we may have an obligation to disclose your PHI to your health plan in order to obtain payment. We may also disclose your PHI to third parties for collection of payment.
  • Healthcare operations: We may use and disclose your PHI for certain healthcare operations, for example, quality assessment and improvement, training and evaluation of healthcare professionals, licensing, accreditation, and other business activities that are part of providing healthcare.
  • Business associates: We may contract with business associates to perform certain functions or activities on our behalf, such as payment and healthcare operations. These business associates must agree to safeguard your PHI.
  • Appointment reminders: We may use your PHI to contact you about appointments for treatment or other healthcare you may need.
  • Identity verification: We may photograph you for identification purposes, storing the photo in your medical record. This is for your protection and safety, but you may opt out.
  • Organized healthcare arrangement: Maui Health System, a Kaiser Foundation Hospitals, LLC (MHS), participates in an organized healthcare arrangement with Kaiser Permanente – Hawaii Region, which includes Kaiser Foundation Hospitals, The Hawaii Permanente Medical Group, and Kaiser Foundation Health Plan, Inc., for the purpose of conducting joint quality assessment and improvement activities and other joint healthcare operations. The OHCA also includes the individual and medical group providers whose members serve on the medical staff of the MHS facilities. We may share your PHI with these organizations and individuals in order to carry out such healthcare operational activities.
  • Health information exchange: We may share your health information electronically with other organizations through health information exchange (HIE) networks. These other organizations may include hospitals, laboratories, healthcare providers, public health departments, health plans, and other participants. Sharing information electronically is a faster way to get your health information to the healthcare providers treating you. For example, if you go to a hospital emergency room that participates in the same HIE network as MHS, the emergency room physicians would be able to access your health information to help make treatment decisions for you. HIE participants are required to meet rules that protect the privacy and security of your health and personal information. You can choose not to have your information shared through any of our HIE networks (that is, "opt out") at any time.

You may do this by contacting the Health Information Management department at Maui Memorial Medical Center, 221 Mahalani Street, Wailuku, Hawaii 96793. You will be asked to complete and submit an opt-out form. If you opt out, the healthcare providers treating you may still obtain your health information in another way, such as by fax, instead of accessing the information through the HIE network.

Specific types of PHI: There are stricter requirements for use and disclosure of some types of PHI, for example, drug and alcohol abuse treatment records. However, there are still circumstances in which this information may be used or disclosed without your authorization.

  • Communications with family and others when you are present: Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we won't discuss your PHI or we will ask the person to leave.
  • Communications with family and others when you are not present: There may be times when it is necessary to disclose your PHI to a family member or other person involved in your care because there is an emergency, you are not present, or you lack the decision making capacity to agree or object. In those instances, we will use our professional judgment to determine if it's in your best interest to disclose your PHI. If so, we will limit the disclosure to the PHI that is directly relevant to the person's involvement with your healthcare. For example, we may allow someone to pick up a prescription for you.
  • Disclosure in case of disaster relief: We may disclose your name, city of residence, age, gender, and general condition to a public or private disaster relief organization to assist disaster relief efforts, unless you object at the time.
  • Disclosures to parents as personal representatives of minors: In most cases, we may disclose your minor child's PHI to you. In some situations, however, we are permitted or even required by law to deny your access to your minor child's PHI. Examples of when we may deny such access include certain situations involving family planning services, sexually transmitted diseases, HIV, ARC or AIDS, and alcohol or substance abuse treatment.
  • Facility directories: When you are a patient in one of our facilities, we may create a directory that includes your name, room location, and your general condition. This information may be disclosed to a person who asks for you by name. In addition, we may provide your religious affiliation, if any, to clergy. You may object to the use and disclosure of some or all of this information. If you do, we will not disclose it to visitors and other members of the public.
  • Research: Our facilities and providers engage in extensive and important research. Some of our research may involve medical procedures and some is limited to collection and analysis of health data. Research of all kinds may involve the use or disclosure of your PHI. Your PHI can generally be used or disclosed for research without your permission if an institutional review board (IRB) approves such use or disclosure. An IRB is a committee that is responsible, under federal law, for reviewing and approving human subjects research to protect the safety of the participants and the confidentiality of PHI.
  • Organ donation: We may use or disclose PHI to organ-procurement organizations to assist with organ, eye, or other tissue donations.
  • Public health activities: Public health activities cover many functions performed or authorized by government agencies to promote and protect the public's health and may require us to disclose your PHI.
    • For example, we may disclose your PHI as part of our obligation to report to public health authorities certain diseases, injuries, conditions, and vital events such as births. Sometimes we may disclose your PHI to someone you may have exposed to a communicable disease or who may otherwise be at risk of getting or spreading the disease.
    • The Food and Drug Administration (FDA) is responsible for tracking and monitoring certain medical products, such as pacemakers and hip replacements, to identify product problems and failures and injuries they may have caused. If you have received one of these products, we may use and disclose your PHI to the FDA or other authorized persons or organizations, such as the maker of the product.
    • We may use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety.
  • Health oversight: As healthcare providers, we are subject to oversight conducted by federal and state agencies. These agencies may conduct audits of our operations and activities and in that process, they may review your PHI.
  • Workers' compensation: We may use and disclose your PHI in order to comply with workers' compensation laws. For example, we may communicate your medical information regarding a work-related injury or illness to claims administrators, insurance carriers, and others responsible for evaluating your claim for workers' compensation benefits.
  • Military activity and national security: We may sometimes use or disclose the PHI of armed forces personnel to the applicable military authorities when they believe it is necessary to properly carry out military missions. We may also disclose your PHI to authorized federal officials as necessary for national security and intelligence activities or for protection of the president and other government officials and dignitaries.
  • Fundraising: We may use or disclose your demographic information and other limited PHI such as dates and where healthcare was provided, to certain organizations for the purpose of contacting you to raise funds for our organization. If we contact you for fundraising purposes, we will provide you with a clear opportunity to elect not to receive any further fundraising communications.
  • Required by law: In some circumstances, federal or state law requires that we disclose your PHI to others. For example, the secretary of the Department of Health and Human Services may review our compliance efforts, which may include seeing your PHI.
  • Lawsuits and other legal disputes: We may use and disclose PHI in responding to a court or administrative order, a subpoena, or a discovery request. We may also use and disclose PHI to the extent permitted by law without your authorization, for example, to defend a lawsuit or arbitration.
  • Law enforcement: We may disclose PHI to authorized officials for law enforcement purposes, for example, to respond to a search warrant, report a crime on our premises, or help identify or locate someone.
  • Serious threat to health or safety: We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else's.
  • Abuse or neglect: By law, we may disclose PHI to the appropriate authority to report suspected child abuse or neglect or to identify suspected victims of abuse, neglect, or domestic violence.
  • Coroners and funeral directors: We may disclose PHI to a coroner or medical examiner to permit identification of a body, determine cause of death, or for other official duties. We may also disclose PHI to funeral directors.
  • Inmates: Under the federal law that requires us to give you this notice, inmates do not have the same rights to control their PHI as other individuals. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your PHI to the correctional institution or the law enforcement official for certain purposes, for example, to protect your health or safety or someone else's.


Except for those uses and disclosures described above, we will not use or disclose your PHI without your written authorization. Some instances in which we may request your authorization for use or disclosure of PHI are:

  • Marketing: We may ask for your authorization in order to provide information about products and services that you may be interested in purchasing or using. Note that marketing communications do not include our contacting you with information about treatment alternatives, prescription drugs you are taking, or health-related products or services that we offer. Marketing also does not include any face-to-face discussions you may have with your providers about products or services.
  • Sale of PHI: We may only sell your PHI if we received your prior written authorization to do so.
  • Psychotherapy notes: On rare occasions, we may ask for your authorization to use and disclose "psychotherapy notes." Federal privacy law defines "psychotherapy notes" very specifically to mean notes made by a mental health professional recording conversations during private or group counseling sessions that are maintained separately from the rest of your medical record. Generally, we do not maintain psychotherapy notes, as defined by federal privacy law.

When your authorization is required and you authorize us to use or disclose your PHI for some purpose, you may revoke that authorization by notifying us in writing at any time. Please note that the revocation will not apply to any authorized use or disclosure of your PHI that took place before we received your revocation.


If you have any questions about this notice, or want to lodge a complaint about our privacy practices, please let us know by calling or writing to: MHS Compliance Officer at Maui Memorial Medical Center, 221 Mahalani Street, Wailuku, Hawaii 96793, telephone number: 808.442.5232. You also may notify the secretary of the Department of Health and Human Services.

We will not take retaliatory action against you if you file a complaint about our privacy practices.


We may change this notice and our privacy practices at any time, as long as the change is consistent with state and federal law. Any revised notice will apply both to the PHI we already have about you at the time of the change, and any PHI created or received after the change takes effect. If we make an important change to our privacy practices, we will promptly change this notice and make the new notice available at the hospital, at all the clinics, and on the MHS website at Except for changes required by law, we will not implement an important change to our privacy practices before we revise this notice.

IX. EFFECTIVE DATE OF THIS NOTICE: This notice is effective on July 1, 2017.