DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tongan)

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington.

The document is provided in Tongan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
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Download a printable version of DSHS Form 03-387 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Koe fanongonongo ‘a e DSHS ki he
Malu’I ko ia ‘a e ‘inifomeisini fakametikolo ‘a e Kalaieni
Kamata ‘i Sepitema 23, 2013
DSHS Kuo pau ke fanongonongo atu ‘a ho totonu malu’i ‘o fekau’aki moe Health Information Portability and Accountability Act (HIPAA).
(45 CFR 164.520). DSHS ko ha “tipaatimeni va’ava’a”. ‘Oku ‘i ai pe ‘a e ‘u tipaatimeni he DSHS ‘oku ‘ikai kau ‘i he malumalu ‘oe HIPAA,
koe ‘u polokalama pe he lisi ‘o e Konga Tauhi Mo’ui ‘a e DSHS he uepisaiti
Health Care Components on the DSHS website
‘oku ‘i he
malumlu ‘o e HIPAA. Koe fanongonongo atu ko’eni ‘oku kau pe ia ki he kalaieni ‘oku fai ki ai ‘a e ngaue na’e ‘i he malumalu ‘o e ngaahi
polokalama. ‘Oku ‘ikai ke uesia ai ho’o kualafai ki he ‘u sevesi ‘a e DSHS.
‘Oku fakamatala he fanongonongo ko‘eni ‘a e founga ‘oku tufaki mo faka’aonga’i ai moe founga teke
lava ai ‘o ma’u ‘a e ‘u ‘inifomeisini. Kataki ‘o vakai’i fakalelei.
Koe ha ‘a e PHI?
Protected Health Information (PHI) ko ha ‘inifomeisini fakametikolo ‘a e kalaieni ‘oku mapukepuke
‘i he konga ‘o e DSHS ‘a ia ‘oku ‘i he fakamalumalu ‘o e HIPAA. Koe PHI ko ha ‘inifomeisini
metikolo kiate koe ‘o fekau’aki mo ho tu’unga mo’ui lelei, ngaue tauhi na’e fai kiate koe, pe koe
totongi mo’ua ki hono tauhi koe. Kuo pau ke hanga he DSHS ‘o malu’i fakalao ho PHI.
Koe ha ‘a e PHI ‘oku ma’u he
Ke toe lelei ‘emau ngaue atu kiate koe, kuo pau keke ‘omai ‘a e ‘inifomeisini metikolo pe koe mo’ui
DSHS ‘o kau kiate au?
lelei ‘o kau ‘ai ‘a e fetu’u ‘oku ke ‘i ai, ‘inifomeisini fakapa’anga pe koe ngaahi lekooti metikolo. Te
mau lava pe ke ma’u ‘a e PHI kiate koe mei ha ngaahi feitu’u kehe kapau ‘oku fiema’u ki hono
tauhi koe pe koe totongi’i ‘a e ngaue ‘oku fai atu.
Ko hai ‘oku sio ki he ‘eku PHI?
‘Oku mau sio pe ki he si’isi’i taha ‘o e PHI ke fai ‘aki ‘emau ngaue. Te mau lava pe ‘o vahevahe ‘a
e PHI mo ha toe ‘u polokalama pe ko ha taha kapau ‘oku ngofua fakalao pe ko ha taha ‘oku ke loto
ki ai. Fakatata’aki ‘eni, ‘e lava pe ke ‘ave mo faka’aogna’i ho PHI ki he Health Care Authority pea
mo ha toe kautaha tauhi mo’ui lelei ke nau fengaue’aki ki hono totongi ‘a e ngaue tauhi ‘oku fai
atu. Teu lava pe ke vahevahe ‘a e ‘u PHI he kuohili, lolotonga pe moe kaha’u.
‘Oku mau vahevahe pe ‘a e PHI ‘oku fiema’u ‘ekinautolu ke fai ‘aki ‘enau ngaue pea fakatatau moe
Koe ha ‘a e PHI ‘oku vahevahe
ngofua ‘a e lao. Teke lava pe ‘o kole ha lisi ‘o kia kinautolu kuo sio ki ho PHI mo hono ‘uhinga.
atu he DSHS?
Ko fe ‘a e taimi ‘oku vahevahe ai
‘Oku mau vahevahe ‘a e PHI ‘i “taimi pe ‘oku fiema’u ai” ‘o fengaue’aki moe ‘u sevesi ki ha faito’o,
he DSHS ‘a e PHI?
totongi mo’ua, moe ngaue tauhi mo’ui lelei. Hange ko’eni, temau lava ‘o vahevahe ha ‘inifomeisini
ki hono fakakaukau’i:
• Koe faito’o fakametikolo ‘oku tonu ke ma’u.
• Te mau lava ‘o totongi ‘a e ‘u sevesi ‘a e ‘u kautaha tauhi mo’ui.
• Pe ‘oku ke kualafai ki he ‘u polokalama ‘a e DSHS.
• Koe tauhi mei he ‘u kautaha ‘oku tatau moe tu’unga fakalao ‘o e ngaue.
Teu lava ‘o sio ki he ‘eku PHI?
Teke lava pe ke sio ki ho PHI. Kapau te ke kole, ‘e ma’u atu ho PHI. ‘E lava pe ke ‘oatu ha totongi
ki he ‘u kopi ko ia.
Kapau ‘oku ke pehe ‘oku hala ho PHI, teke lava pe ‘o kole mai ke liliu pe tanaki atu ki he PHI. Teke
Teu lava ‘o liliu ‘eku PHI?
lava pe ‘o kole ke mau ‘oatu ha ‘u liliu kiate kinautolu ‘oku nau ma’u ho PHI.
Fefe nai kapau ‘e fiema’u ha taha
Te ke lava ‘o kole ha foomu ‘o fakamo’oni ai ke mau fevahevahe’aki ho PHI kapau:
kehe ‘eku PHI?
• ‘Oku mau fiema’u ha’o ngofua ke fai ha ngaue pe ko ha tauhi;
• ‘Oku ke fiema’u ke mau ‘oatu ho PHI ki ha tipaatimeni pe ko ha kautaha ‘aki ha ‘uhinga ‘oku
‘ikai ngofua fakalao pea ‘ikai ai ke ma’u ha ngaofua mei ate koe. ;
• ‘Oku ke fiem’au ke ‘ave ho PHI ki ha taha kehe, hange ko ho loea, famili, pe ko ha toe
fakafofonga kehe.
Ko ho fakangofua ke fevahevahe’aki ho PHI ‘oku lelei pe ‘o a’u ki he ‘aho ‘oku ke hiki he foomu. Te
mau vahevahe pe ho PHI ‘o fakatatau ki ho lisi. Teke lava ‘o kaniseli pe liliu ‘aki ha’o tohi
fakangofua ki he DSHS.
DSHS 03-387 TN (REV. 09/2021) Tongan
Koe fanongonongo ‘a e DSHS ki he
Malu’I ko ia ‘a e ‘inifomeisini fakametikolo ‘a e Kalaieni
Kamata ‘i Sepitema 23, 2013
DSHS Kuo pau ke fanongonongo atu ‘a ho totonu malu’i ‘o fekau’aki moe Health Information Portability and Accountability Act (HIPAA).
(45 CFR 164.520). DSHS ko ha “tipaatimeni va’ava’a”. ‘Oku ‘i ai pe ‘a e ‘u tipaatimeni he DSHS ‘oku ‘ikai kau ‘i he malumalu ‘oe HIPAA,
koe ‘u polokalama pe he lisi ‘o e Konga Tauhi Mo’ui ‘a e DSHS he uepisaiti
Health Care Components on the DSHS website
‘oku ‘i he
malumlu ‘o e HIPAA. Koe fanongonongo atu ko’eni ‘oku kau pe ia ki he kalaieni ‘oku fai ki ai ‘a e ngaue na’e ‘i he malumalu ‘o e ngaahi
polokalama. ‘Oku ‘ikai ke uesia ai ho’o kualafai ki he ‘u sevesi ‘a e DSHS.
‘Oku fakamatala he fanongonongo ko‘eni ‘a e founga ‘oku tufaki mo faka’aonga’i ai moe founga teke
lava ai ‘o ma’u ‘a e ‘u ‘inifomeisini. Kataki ‘o vakai’i fakalelei.
Koe ha ‘a e PHI?
Protected Health Information (PHI) ko ha ‘inifomeisini fakametikolo ‘a e kalaieni ‘oku mapukepuke
‘i he konga ‘o e DSHS ‘a ia ‘oku ‘i he fakamalumalu ‘o e HIPAA. Koe PHI ko ha ‘inifomeisini
metikolo kiate koe ‘o fekau’aki mo ho tu’unga mo’ui lelei, ngaue tauhi na’e fai kiate koe, pe koe
totongi mo’ua ki hono tauhi koe. Kuo pau ke hanga he DSHS ‘o malu’i fakalao ho PHI.
Koe ha ‘a e PHI ‘oku ma’u he
Ke toe lelei ‘emau ngaue atu kiate koe, kuo pau keke ‘omai ‘a e ‘inifomeisini metikolo pe koe mo’ui
DSHS ‘o kau kiate au?
lelei ‘o kau ‘ai ‘a e fetu’u ‘oku ke ‘i ai, ‘inifomeisini fakapa’anga pe koe ngaahi lekooti metikolo. Te
mau lava pe ke ma’u ‘a e PHI kiate koe mei ha ngaahi feitu’u kehe kapau ‘oku fiema’u ki hono
tauhi koe pe koe totongi’i ‘a e ngaue ‘oku fai atu.
Ko hai ‘oku sio ki he ‘eku PHI?
‘Oku mau sio pe ki he si’isi’i taha ‘o e PHI ke fai ‘aki ‘emau ngaue. Te mau lava pe ‘o vahevahe ‘a
e PHI mo ha toe ‘u polokalama pe ko ha taha kapau ‘oku ngofua fakalao pe ko ha taha ‘oku ke loto
ki ai. Fakatata’aki ‘eni, ‘e lava pe ke ‘ave mo faka’aogna’i ho PHI ki he Health Care Authority pea
mo ha toe kautaha tauhi mo’ui lelei ke nau fengaue’aki ki hono totongi ‘a e ngaue tauhi ‘oku fai
atu. Teu lava pe ke vahevahe ‘a e ‘u PHI he kuohili, lolotonga pe moe kaha’u.
‘Oku mau vahevahe pe ‘a e PHI ‘oku fiema’u ‘ekinautolu ke fai ‘aki ‘enau ngaue pea fakatatau moe
Koe ha ‘a e PHI ‘oku vahevahe
ngofua ‘a e lao. Teke lava pe ‘o kole ha lisi ‘o kia kinautolu kuo sio ki ho PHI mo hono ‘uhinga.
atu he DSHS?
Ko fe ‘a e taimi ‘oku vahevahe ai
‘Oku mau vahevahe ‘a e PHI ‘i “taimi pe ‘oku fiema’u ai” ‘o fengaue’aki moe ‘u sevesi ki ha faito’o,
he DSHS ‘a e PHI?
totongi mo’ua, moe ngaue tauhi mo’ui lelei. Hange ko’eni, temau lava ‘o vahevahe ha ‘inifomeisini
ki hono fakakaukau’i:
• Koe faito’o fakametikolo ‘oku tonu ke ma’u.
• Te mau lava ‘o totongi ‘a e ‘u sevesi ‘a e ‘u kautaha tauhi mo’ui.
• Pe ‘oku ke kualafai ki he ‘u polokalama ‘a e DSHS.
• Koe tauhi mei he ‘u kautaha ‘oku tatau moe tu’unga fakalao ‘o e ngaue.
Teu lava ‘o sio ki he ‘eku PHI?
Teke lava pe ke sio ki ho PHI. Kapau te ke kole, ‘e ma’u atu ho PHI. ‘E lava pe ke ‘oatu ha totongi
ki he ‘u kopi ko ia.
Kapau ‘oku ke pehe ‘oku hala ho PHI, teke lava pe ‘o kole mai ke liliu pe tanaki atu ki he PHI. Teke
Teu lava ‘o liliu ‘eku PHI?
lava pe ‘o kole ke mau ‘oatu ha ‘u liliu kiate kinautolu ‘oku nau ma’u ho PHI.
Fefe nai kapau ‘e fiema’u ha taha
Te ke lava ‘o kole ha foomu ‘o fakamo’oni ai ke mau fevahevahe’aki ho PHI kapau:
kehe ‘eku PHI?
• ‘Oku mau fiema’u ha’o ngofua ke fai ha ngaue pe ko ha tauhi;
• ‘Oku ke fiema’u ke mau ‘oatu ho PHI ki ha tipaatimeni pe ko ha kautaha ‘aki ha ‘uhinga ‘oku
‘ikai ngofua fakalao pea ‘ikai ai ke ma’u ha ngaofua mei ate koe. ;
• ‘Oku ke fiem’au ke ‘ave ho PHI ki ha taha kehe, hange ko ho loea, famili, pe ko ha toe
fakafofonga kehe.
Ko ho fakangofua ke fevahevahe’aki ho PHI ‘oku lelei pe ‘o a’u ki he ‘aho ‘oku ke hiki he foomu. Te
mau vahevahe pe ho PHI ‘o fakatatau ki ho lisi. Teke lava ‘o kaniseli pe liliu ‘aki ha’o tohi
fakangofua ki he DSHS.
DSHS 03-387 TN (REV. 09/2021) Tongan
Koe fanongonongo ‘a e DSHS ki he Malu’i ko ia ‘ae ‘inifomeisini fakametikolo ‘a e Kalaieni
Kamata ‘i Sepitema 23, 2013
‘E lava nai he DSHS ‘o vahevahe
‘E lava pe he DSHS ‘o vahevahe ho PHI ta’ema’u ha ngofua meiate koe ‘i ha ngahi taimi pe. ‘O
‘eku PHI ta’ema’u ha ngofua
fakatatau moe lao, te mau lava pe, pe koe ngofua ke vahevahe ho PHI. Ngaahi fakatata ‘eni ‘oku
meiate au?
kau ai ‘a e fiema’u:
• Lipooti ‘o ha me’a na’e hoko ki he fanau pe ko ha tauhi kovi pe ta’etokanga’i ki he Child
Protective Services, pe koe kau polisi pe ko ha tipaatimeni kehe.
• Talatu’utu’uni ‘a e fakamaau’anga ke ‘oatu ‘a e lekooti.
• ‘Oatu ‘a e PHI ki he ‘u tipaatimeni kehe ‘oku nau vakai’i ‘a e ngaue ‘o e DSHS.
• Vahevahe ‘a e PHI mo ha ‘u tipaatimeni ‘oku nau laiseni mo ‘inisipekita’i ‘a e ‘u fale
fakametikolo, hange koe ‘u ‘api neesi moe falemahaki.
• Vahevahe ‘a e PHI moe ‘u kautaha sevesi pe koe ‘u tipaatimeni ‘oku ngaue tauhi kiate koe pe
ko ha fiema’u ke ‘ilo’i pe ‘oku ke kualafai ki he ‘u sevesi moe ‘u penefiti.
• ‘Oange PHI ki he tokotaha tauhi pe ko ha matu’a ‘o ha tamasi’i.
• Faka’aonga’i ‘a e PHI ki ha fekumi.
• Faka’aonga’i pe koe fakahaa ‘a e PHI ‘I ha taimi fakatamaki pe ko ha ‘uhinga ke fakaleleli’i ai
ha fakatu’utamaki.
Teu lava nai ‘o fakangatangata
Teke lava pe ‘o kole mai ke fakangatangata hono faka’aonga’i mo hono vahevahe ho PHI ka ‘oku
hono vahevahe ‘eku PHI moe
‘ikai ‘uhinga ia te mau loto ki ai. Teke lava pe ‘o toe kole ke mau ‘oatu ho PHI kiate koe ‘i ha
founga teu ma’u ai ia.
foameti kehe pe ko ha feitu’u kehe.
Koe ha ‘a e breach?
Koe breach ‘oku faka’aonga’i pe koe fakahaa ho PHI ‘oku ‘ikai ngofua he malumalu ‘o e HIPAA,
kau ai ‘a e mole ‘i ha kaiha’a, fehala’aki pe koe Heki. Te mau tala ‘atu he meili kapau ‘oku ‘i ai ha
breach ‘a ho’o PHI ‘i he malumalu ‘o e HIPAA.
Teu lava ‘o ma’u ha kopi ‘oe tohi
‘Io. Koe tohi koi a ke ke tauhi. Kapau na’ake ma’u ia ‘ilekitolonika, ‘e lava pe ke ke kole ha kopi
ko ia?
pepa pea te mau ‘oatu ia.
Fefe kapau ‘e liliu ‘a e ‘u lao
Kuo pau ke mau muimui ki he tohi fonongonongo ko ‘eni. ‘Oku ‘i ai ‘emau totonu ke mau liliu ‘a e
ngaue ki he PHI?
fanongonongo. Kapau ‘oku liliu ‘a e lao pe koe ngaue fakalao ki hono malu’i, te mau ‘oatu ‘a e ‘u
‘inifomeisini ‘o kau ki he liliu ko ia moe feitu’u ke ‘ilo’i ai ia pe ko hono li atu kiate koe.
Ko hai teu fetu’utaki ki ai kapau
Kapau ‘oku ‘i ai ha’o fehu’i ki he fanongonongo, teke lava pe ‘o fetu’utaki ki he DSHS Privacy
‘oku ‘i ai ha fehu’i ki he ‘u
Officer he
DSHSPrivacyOfficer@dshs.wa.gov
pe koe (360) 902-8278.
fanongonongo pe ko ‘eku totonu
fakalao ki he PHI?
‘Oku anga fefe hono lipooti ha
Kapau ‘oku ke tui kuo ‘i ai ha maumau lao ki ho PHI ‘e lava keke faile ha launga moe:
maumau lao ki he ‘eku PHI mo
DSHS Privacy Officer, Department of Social and Health Services, PO Box 45135, Olympia WA
hono ngaahi totonu?
98504-5135 pe koe meili DSHSPrivacyOfficer@dshs.wa.gov. Kapau teke faile ha launga, ‘e ‘ikai
lava he DSHS ke liliu pe ta’ofi ‘a e ‘u sevesi pea tapu ke nau fai ha sauni kiate koe.
PE KOE
‘Ave ho launga he ‘initaneti ki he:
https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf
pe ko ho
200
tohi ki he: Office for Civil Rights, US Department of Health and Human Services,
Independence Avenue, S.W., Room 509F HHH Bldg., Washington ,D.C. 20201
, telefoni
(800) 368-1019. Ka ‘i ai ha toe launga ki he DHHS kuo pau ke fai ia kimu’a he ‘aho 180 mei he
taimi na’e hoko ai ‘a e maumau lao.
DSHS 03-387 TN (REV. 09/2021) Tongan
Koe fanongonongo ‘a e DSHS ki he Privacy Practices for Client Medical Information
Kamata ‘i Sepitema 23, 2013
Fakatokanga’i ange
Acknowledgement
(‘Oku fiema’u ‘i he taimi ‘oku fai hangatonu ai he DSHS ‘a e ngaue tauhi fakafaito’o)
HINGOA KALAIENI
‘AHO FA’ELE’I KALAIENI
Kuo ou ma’u ‘a e kopi mei he DSHS Privacy Notice pea ma’u faingamalie ke fai ha fehu’i ‘o fekau’aki moe DSHS ki hono
faka’aonga’i pea mo hono vahevahe ‘ a ‘eku Personal Health Information.
KALAIENI PE KO HA FAKAFOFONGA FAKAMO’ONI
TEITI
FOR DSHS USE ONLY
To be completed if unable to obtain signature of client or personal representative.
Describe efforts made to have the client acknowledge receipt of the Notice of Privacy Practices (NPP):
Describe reason why acknowledgement was not obtained:
STAFF MEMBER’S NAME AND TITLE (PLEASE PRINT)
ADMINISTRATION/DIVISION
STAFF’S SIGNATURE
DATE
DSHS 03-387 TN (REV. 09/2021) Tongan
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