1329 Lusitana Street, Suite #402 Honolulu, Hawaii 96813 Telephone (808) 538-3787

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. The privacy of your medical information is important to us. This Notice of Privacy Practices 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 or PHI is information about you, including demographic information, that may identify you and that relates to your past, present and future physical or mental health or condition and related health care services. This notice takes effect on October 01, 2003 and will remain in effect until we replace it. We are required to abide by the terms of this Notice of Privacy Practices. We are also required to give you this notice describing our privacy practices, legal duties and your rights regarding your medical information. We may revise or amend the terms of our notice, at any time without prior notice. The new notice will be effective for all protected health information that we maintain at that time including information previously created or received before the changes and for any of your records that we may create or maintain in the future. You may obtain a copy of any revised Notice of Privacy Practices by calling the office or requesting in writing that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

USES AND DISCLOSURES OF HEALTH INFORMATION

TREATMENT: We may use and disclose health information about you to provide, coordinate or manage your health care and other related services. We may disclose your protected health information to another physician, nurse, technician, medical student or other people who are taking care of you. For example, we may also share medical information about you to your other health care providers to assist them in treating you. PAYMENT: We may use and disclose your health information to obtain payment for your health care services. For example, this may include, but is not limited to, certain activities that your health insurance plan may undertake before it approves or pays for health care services and disclosures to billing services or collection agencies. HEALTHCARE OPERATIONS: We may use or disclose your protected health information in order to support the business activities of our practice. For example, these activities may include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, credentialing, conducting and arranging for other business activities. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary to contact you to schedule, reschedule, confirm or remind you of your appointment and to notify you of test results. Contact and/or notification may be by means of telephone calls, voice mail, postcards or letters. TO YOUR FAMILY, FRIENDS AND PERSONS INVOLVED IN YOUR CARE: We may use and/or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition or death. If you are present, then prior to use and/or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, Doctor’s notes and other similar forms of health information. OTHER USES AND DISCLOSURES OF HEALTH INFORMATION THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT REQUIRED BY LAW: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. PUBLIC HEALTH: We may disclose your health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. COMMUNICABLE DISEASES: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. HEALTH OVERSIGHT: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. ABUSE OR NEGLECT: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

FOOD AND DRUG ADMINISTRATION

We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. LEGAL PROCEEDINGS: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. LAW ENFORCEMENT: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes may include, but is not limited to, reporting of certain types of wounds, reports regarding suspected victims of crimes, criminal conduct on or off the premises and, in an emergency, to report a crime. CORONERS, FUNERAL DIRECTORS AND ORGAN DONATION: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, to permit the funeral director to carry out their duties. Protected health information may also be used and disclosed for cadaveric organ, eye or tissue donation purposes. RESEARCH: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. CRIMINAL ACTIVITY: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or if it is necessary for law enforcement authorities to identify or apprehend an individual. MILITARY ACTIVITY AND NATIONAL SECURITY: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized. WORKERS’ COMPENSATION: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. INMATES: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. REQUIRED USES AND DISCLOSURES: Under the law, we must make disclosures to you upon your request and when required by the Secretary of the Department of Health and Human Services (DHHS) to investigate or determine our compliance with federal law.

YOUR RIGHTS

ACCESS: You have the right to inspect and obtain a copy of your protected health information that may be used to make decisions about you, including medical and billing records. Certain notes/records may be restricted by law and not available for access. Requests must be submitted in writing to the Physician and/or Privacy Officer to inspect and/or obtain a copy of your medical record. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request under certain circumstances; however, you may request a review of our denial. CONFIDENTIAL COMMUNICATIONS: You have the right to request that our practice communicate with you by an alternative means or at an alternative location. Our practice will accommodate reasonable requests. Requests must be submitted in writing to the Physician and/or Privacy Officer. RESTRICTIONS: You have the right to request a restriction in the use or disclosure of your protected health information for treatment, payment or health care operations. You also have the right to restrict disclosure of your health information to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law or when the information is necessary to treat you. Requests must be submitted in writing to the Physician and/or Privacy Officer. AMENDMENT: You have the right to ask our practice to amend your health information if you believe it is incorrect or incomplete. You may request an amendment for as long as the information is kept by or for our practice. Requests must be submitted in writing to the Physician and/or Privacy Officer. A request for amendment may be denied in certain circumstances. Reasons for denial include, but are not limited to; (a) in our opinion original information is accurate and complete; (b) information is restricted for inspection or copying; or (c) not created by our practice, unless the individual or entity that created the information is not available to amend the information. ACCOUNTING OF DISCLOSURES: This right applies to disclosures for the purposes other than treatment, payment or healthcare operations. Use of your protected health information as part of the routine patient care is not required to be documented. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. Requests must be submitted in writing to the Physician and/or Privacy Officer. AUTHORIZATION FOR OTHER USES AND DISCLOSURES: Our practice will obtain your written authorization for uses and disclosures that are not required or permitted by applicable law. Requests must be submitted in writing to the Physician and/or Privacy Officer. You may revoke this authorization at any time, in writing, except to the extent that action has been taken in reliance on your authorization. Certain exceptions, restrictions and limitations may apply. PAPER COPY OF THIS NOTICE: You have a right to receive a paper copy of this notice of privacy practices.

QUESTIONS AND COMPLAINTS

If you have any questions or concerns about this notice or request additional information, please contact our office. If you think that we may have violated your privacy rights, please submit a written complaint to the Privacy Officer, c/o (name of Physician), 1329 Lusitana Street #402, Honolulu, HI 96813. Your complaint must be filed within 180 days of when you knew or should have known that the act or omission complained of occurred, unless the time limit is waived by the DHHS for good cause shown. We will not retaliate against you for filing a complaint. You may also file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. Rev 09/2003