Mary Church, Ph.D.
1188 Bishop Street, Suite 3105
Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
Patient Bill of Rights
You have the right to:* Request and receive information about the Provider’s professional capabilities, including licensure,
education, training, experience, professional association membership, specialization, and limitations.
* Verify Provider’s status with the Board of Psychology and receive information about any discipline.
* Have written information about fees, methods of payment, insurance reimbursement, number of sessions,length of sessions, professional assistance when your psychologist is not available (in cases of vacation andemergencies), and cancellation policies before beginning therapy. This kind of information is referred to as
informed consent.
* Know the limits of confidentiality and the circumstances in which a psychologist is legally required todisclose information to others.
* Receive a verbal or written treatment plan.
* Have a safe environment, free from sexual, physical or emotional abuse.
* Expect that your Provider should not involve you in any social or business relationship that conflicts withyour therapy relationship.
* Ask questions about your therapy or psychological assessment.
* Refuse to answer any question or disclose any information you choose not to reveal.
* Request that the Provider inform you of your progress.
* Know if there are supervisors, consultants, students, directed service providers or others with whom yourProvider will discuss your case.
* Refuse a particular type of treatment or end treatment at any time without obligation or harassment.
* Refuse or request electronic recording of your sessions.
* Request and (in most cases) receive a summary of your records, including the diagnosis, treatment plan,your progress, and type of treatment.
* Report unprofessional behavior by a Provider.
* Receive a second opinion at any time about your therapy or about your Provider’s methods.
* Receive referral names, addresses and telephone numbers in the event that your therapy needs to betransferred to someone else and to request that a copy or a summary of your records be sent to any therapist
or agency you choose.

Mary Church, Ph.D.
1188 Bishop Street, Suite 3105
Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
An Introduction to Privacy Rights for Clients
You may have heard about the complex new federal privacy rule under the Health Insurance Portability andAccountability Act, better known as HIPAA. It is important that, as a client of Dr. Church, you understandwhat this rule means, and how it could affect you.
In general, HIPAA establishes requirements for how your therapist -- as well as other health care
professionals and organizations -- use and disclose your records. HIPAA also provides certain basic privacy
rights and helps clarify all patient privacy rights, including those that exist under state law.

Following is a brief summary of the HIPAA rule. Attached you will also find a detailed notice ofyour privacy rights, which is a requirement of HIPAA.
Under the HIPAA rules:I will exercise great care in handling your records to prevent unauthorized individuals from seeingthem.

You generally have the right to review your records, receive a copy of them, and request that anyerrors be corrected. In certain situations, I have the right to deny such requests.

You have increased protection from insurance companies and others who may ask to see yourrecords.

You are able to request certain restrictions on the disclosure of your records –although I may use my best judgment about whether to comply with your request.

You have the right to receive confidential communications of health information
at any location you specify. For example, a client may request that a bill be sent to an address otherthan his or her home, or ask me not to leave any messages on a home answering machine.

Be assured that Dr. Church considers maintaining client privacy a critical component of her practice. The
Notice of Private Practices attached to this letter explains Dr. Church’s privacy practices in greater detail,which is a requirement of HIPAA.
Please let me know if you have any questions about this Notice of Privacy Practices.
You may contact the Privacy Officer at: 1188 Bishop Street, Suite 905, Honolulu, HI 96813, (808) 479-7670, anddiscuss any questions you may have with Dr. Church.

Mary Church, Ph.D.
1188 Bishop Street, Suite 3105

Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
NOTICE OF PRIVACY PRACTICES OF MARY CHURCH, PH.D.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION. PLEASE REVIEW IT CAREFULLY.
Mary Church, Ph.D. is a health care provider who delivers psychological services. Dr. Church creates andmaintains treatment records that contain individually identifiable health information about her clients. Theserecords are generally referred to as medical records or mental health records, and this notice, concerns theprivacy and confidentiality of those records and the information contained therein.
I. Disclosures For Treatment, Payment, or Health Care Operations
I may use and disclose your protected health information (PHI) for certain treatment, payment, and healthcare operations
purposes without your authorization. In certain circumstances I can only do so when the person or business
requesting your PHI gives me a written request that includes certain promises regarding protecting theconfidentiality of your PHI. To help clarify these terms, here are some definitions:“PHI” refers to information in your health record that could identify you.

“Treatment and Payment Operations:”—“Treatment” is when I provide or another healthcare provider diagnoses or treats you. An

example of treatment would be when I consult with another healthcare provider, such as your family
physician or another psychologist, regarding your treatment.
—“Payment” is when I obtain reimbursement for your healthcare. Examples of payment are whenI disclose your PHI to your health insurer to obtain reimbursement for your health care or todetermine eligibility or coverage.
—“Health Care Operations” is when I disclose your PHI to your health care service plan (e.g. yourhealth care insurer), or to other health care providers contracting with your plan, for administering
the plan, such as case management and care coordination.
“Use” applies only to activities outside of my office/practice, such as sharing, employing, applying,utilizing, examining and analyzing information that identifies you.
“Disclosure” applies to activities outside of my office/practice, such as releasing, transferring, orproviding access to information about you to other parties.
“Authorization” means written permission for specific uses or disclosures.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when yourappropriate authorization is obtained. In those instances when I am asked for information, I will obtain an
authorization from you before releasing this information. I will also need to obtain an authorization before
releasing psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during aprivate, group, joint or family counseling session, which I have kept separate from the rest of your medicalrecord. These notes are given a greater degree of protection than PHI.
You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time, however, therevocation or modification is not effective until I receive it.

Mary Church, Ph.D.
1188 Bishop Street, Suite 3105

Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
III. Uses and Disclosures with Neither Consent nor Authorization
I may disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: Whenever I, in my professional capacity, have knowledge of or observe achild I know, or reasonable suspect, has been the victim of child abuse or neglect, I must
immediately report such to a police department or sheriff’s department, county probation
department, county welfare department (e.g. Child Protective Services). Additionally, if I
have knowledge of or reasonably suspect that mental suffering has been inflicted upon achild, or that his/her emotional wellbeing is endangered in any other way, I must reportsuch to the above agencies.

Adult and Domestic Abuse: If I, in my professional capacity, have observed or haveknowledge of an incident that reasonably appears to be physical abuse, abandonment,abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if I am told
by an elder or dependent adult that he or she has experienced these or if I reasonably suspectsuch, I must report the known or suspected abuse immediately to the local ombudsman orlocal law enforcement agency.

Health Oversight: If a complaint is filed against me with the Hawaii Board of Psychology,
the Board has the authority to subpoena confidential mental health information from me
relevant to that complaint.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and arequest is made about the professional services that I have provided you, I must not release
your information without 1). Your written authorization or the authorization of yourattorney or personal representative; 2). A court order; 3). A subpoena duces tectum (asubpoena to produce records) where the party seeking your records provides me with ashowing that your or your attorney have been served with a copy of the subpoena, affidavit
and the appropriate notice, and you have not notified me that you are bringing a motion in
the court to quash (block) or modify the subpoena. The privilege does not apply when you
are being evaluated for a third party where the evaluation is court ordered. I will inform youin advance if this is the case.

Serious Threat to Health or Safety: If you communicate to me a serious threat of physicalviolence against an identifiable victim, I must make reasonable efforts to communicate that
information to the potential victim and the police. If I have reasonable cause to believe thatyou are in such a condition, as to be dangerous to yourself or others, I may release relevant
information as necessary to prevent the threatened danger.

Workers Compensation: If you file a Worker’s Compensation claim, I must furnish areport to your employer, incorporating my findings about your injury and treatment, within
five working days from the date of your initial examination, and at subsequent intervals as
may be required by the administrative director of the Worker’s Compensation Commissionin order to determine your eligibility for worker’s compensation.

Mary Church, Ph.D.
1188 Bishop Street, Suite 3105

Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
IV. Patient’s Rights and Psychologist’s Duties
1. Right to Request Restrictions – You have the right to request restrictions on certain uses anddisclosures of protected health information about you. However, I am not required to agree to arestriction you request.
2. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You havethe right to request and receive confidential communications of PHI by alternative means and atalternative locations. (For example, you may not want a family member to know that you areseeing me. Upon your request, I will send your bills to another address.)
3. Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in mymental health and billing records used to make decisions about you for as long as the PHI ismaintained in the record. I may deny your access to PHI under certain circumstances, but in somecases you may have this decision reviewed. On your request, I will discuss with you the details ofthe request and denial process.
4. Right to Amend – You have a right to an amendment of PHI for as long as the PHI is maintained inthe record. I may deny your request. On your request I will discuss with you the details of theamendment process.
5. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI
for which you have neither provided consent nor authorization (as described in section III of thisnotice). On your request, I will discuss with you the details of the accounting process.
6. Right to a Paper Copy – You have the right to obtain a paper copy of this notice from me uponrequest, even if you have agreed to receive the notice electronically.
7. Right to File a Complaint – You have the right to file a complaint if you feel your privacy rights havebeen violated. Upon request, Dr. Mary Church will provide you with the information needed to file
your complaint. Under no circumstances will she retaliate against you for filing a complaint.
If a client wishes to learn more detailed information about any of the above rights, or their limitations, please
let your therapist know. She is willing to discuss any of these matters with clients.
The Duties of The Mental Health Professional
Like all mental health professionals, Dr. Church is required by law to maintain the privacy and confidentialityof clients' personal health information. This notice is intended to let her clients know of their legal duties,rights, and Dr. Church’s privacy practices with respect to such information. Dr. Church is required to abideby the terms of the notice currently in effect. Dr. Church reserves the right to change the terms of this notice
and/or privacy practices and to make the changes effective for all protected health information that she
maintains, even if it was created or received prior to the effective date of the notice revision. If Dr. Church
makes a revision to this notice, she will make the notice available at the office upon request on or after theeffective date of the revision and the revised notice will be posted in a clear and prominent location.
If a client of Dr. Church needs or desires further information related to this Notice or its contents, or if he or
she has any questions about this Notice or its contents, please feel free to contact the Privacy Officer. As theMary Church, Ph.D.
1188 Bishop Street, Suite 3105

Honolulu, HI 96813

This is Your Copy – Please Retain for Your Records
Contact Person for this practice, the Privacy Officer will do their best to answer questions and to provide him
or her with additional information.
Privacy Officer Contact Information:
Mary Church, Ph.D. – Licensed Clinical Psychologist
1188 Bishop Street, Suite 3105
Honolulu, HI 96813
Direct phone: (808) 479-7670
This notice first became effective on August 1, 2009