Who Will Follow This Notice

This joint notice describes the practices of:

  • Any health care professional authorized to enter information in your medical record at The Mana Clinic. This includes employees and contracted medical staff. The Mana Clinic and its non-employee medical staff have formed an organized health care arrangement so that The Mana Clinic and its independent providers may share your health information with each other as necessary to carry out treatment, payment, and operations. 
  • All department personnel of The Mana Clinic that comprise The Mana Clinic’s health care component. 

Our Responsibilities

The law protects the privacy of the health information we create and obtain in providing care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information related to these services. Federal and state laws allow us to use and disclose your protected health information for purposes of treatment, payment, and health care operations.

How We May Use and Disclose Medical Information About You 

Your health information may be shared by The Mana Clinic only when necessary for medical treatment or for the health care operations purposes of the organized health care arrangement.  

The personal health information may include past, present and future medical information as well as information outlined in the Privacy Rules.  The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time.  You have the right to change your mind and withdraw this consent, however, the information may have already been provided as allowed by you.  This consent will remain in effect until revoked by you in writing.  If requested, you will be provided a list of entities to which your information has been disclosed. 

For Treatment: Information obtained by a licensed provider or other member of our healthcare team will be recorded in your electronic medical record and used to help decide what care may be right for you. For example, your physician may need to consult with specialists about your care. Information about you would be shared with other providers to help understand your care needs.

Communication with Family and Friends: We may release medical information about you to a family member or friend who is involved in your care and/or helps pay for your care. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical care at our clinic. 

For Payment: We will not disclose your health information to third party payers without your authorization unless allowed to do so by law.

For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to make sure that all of our patients receive quality care. For example:

  • We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
  • We may disclose information to physicians, medical assistants, technicians, or other clinic personnel for review and learning purposes.
  • We may use and disclose your information to conduct or arrange for services, including medical quality reviews; accounting, legal, risk management and insurance services; and audit functions, including fraud and abuse detection and compliance programs.

Other Uses and Disclosures

Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may tell you about health related benefits, services, or health care education classes that may be of interest to you.

Research: We may disclose information to researchers when an institutional review board has approved the research proposal and established protocols to ensure the privacy of your health information. In most circumstances, we will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are.

As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat.

Special Situations

Organ and Tissue Donation: If you are an organ donor, we may release medical information as necessary to facilitate organ or tissue donation and transplantation to organizations that handle organ or tissue procurement and transplantation or to an organ donation bank.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health: As required by law, we may disclose medical information about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at our clinic;
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official necessary for your health and the health and safety of other individuals.

Your Health Information Rights

Right to this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy at any time. You may also obtain a copy of this notice at our website,

Right to Inspect and Copy: You have a right to inspect and receive a copy of certain health care information including certain medical and billing records. To obtain a copy of your records you must submit your request in writing to our Medical Records Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you would like to schedule an appointment to view your record or if you have any questions about your right to inspect and copy your record, please contact the Medical Records at (808) 209-5657.

Note: We are required to retain our records of the care that we provided to you. Although you have the right to exercise control over certain uses and disclosures of your medical information, the medical record The Mana Clinic maintains on your care is property of The Mana Clinic. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical record, you may request that the denial be reviewed. We will comply with the outcome of the review.

Right to Request Amendment: You have a right to ask that your health information be amended by sending a written request to our Medical Records Department.  We have the right to deny this request under certain circumstances. You may write a statement of disagreement if your request is denied. This statement of disagreement will be stored in your medical record, and included with any release of your records.

Right to a List of Disclosures: You have the right to request a list of disclosures. This is a record of certain disclosures we made of medical information about you in accordance with applicable laws.

You must submit your request in writing to our Medical Records Department to obtain a list of disclosures. The first time you request a list within a 12-month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restriction: You have a right to ask us to restrict certain uses and disclosures of your health information. You may be asked to make this request in writing. Ask your caregiver if you have questions about this. We will comply with all reasonable requests. 

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a specific way or location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may be asked to make your request in writing. Ask the person (or department) that gave you this notice for more information about this process. We will comply with all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Revoke Authorization: Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you under these circumstances, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and information disclosed to other party’s may no longer be afforded certain protections under the law once released and might be re-disclosed to other parties without your authorization.

Changes to this Notice

We reserve the right to change this notice at any time. Any revised or changed notice will be effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website


If you believe your privacy rights have been violated, you may contact The Mana Clinic’s Medical Records Department at: 354 Uluniu St. Suite 404, Kailua, HI, 96734; [(808) 206-5657]. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. 

The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

Effective Date of this Notice: September 27, 2020