STATE OF HAWAII
DEPARTMENT OF HEALTH
P. O. BOX 3378
HONOLULU, HI 96801-3378
DAVID Y. IGE
GOVERNOR OF HAWAII
ELIZABETH A. CHAR, M.D.
DIRECTOR OF HEALTH
In reply, please refer to:
File:
January 30, 2021
FOR COVERED ENTITIES AND PROVIDERS: SAMPLE TEMPLATES FOR NON-
DISCLOSURE OF MINOR-INITIATED MENTAL HEALTH CARE FOR HEALTH
PLANS
Pursuant to Act 37 SLH 2020 which amends §577-29, HRS, minors, 14 years of age or older,
may consent to outpatient mental health services without parental or legal guardian consent,
knowledge or participation, after consulting with a licensed mental health professional.
The Child and Adolescent Mental Health Division (CAMHD) offers the attached documents as
SAMPLE templates to assist plans and providers in developing their own policies and
procedures to maintain nondisclosure of the minor-initiated mental health treatment or
counseling services to the parent or legal guardian. The accompanying form “Notice of Non-
Disclosure of Minor-Initiated Mental Health Care for Health Plans” might be completed by a
provider and attached to the “Non-Disclosure of Minor-Initiated Mental Health Care Agreement”
signed by a consenting minor and provider. Both documents might be sent to a covered entity or
health plan to ensure non-disclosure.
Since these are SAMPLE template forms (shared for training purposes only), covered
providers should always consult with the relevant health plan to determine the necessary
documentation. These forms do not replace the insurance plan’s official forms.
Notice Type (check one)
☐ New Non-Disclosure Agreement
☐ Extended Expiration Date of Non-Disclosure
☐ Withdrawal of Non-Disclosure Agreement
NOTICE OF NON-DISCLOSURE OF MINOR-INITIATED MENTAL HEALTH CARE
FOR HEALTH PLANS
Insurance Plan: ________________________________ Phone #: ____________________
Insurance Plan Secure Email Address: ___________________________________________
Minor's Name: _____________________________________________________________
(Last name) (First Name) (Middle Initial)
Minor's Address: _____________________________________________________________
Minor's Date of Birth: ________________ Minor's Health Plan ID: __________________
Mother's Name: _____________________________________________________________
or Legal Guardian (Last name) (First Name) (Middle Initial)
Father's Name: __________________________________________________________________________
or Legal Guardian (Last name) (First Name) (Middle Initial)
Pursuant to §577-29, HRS, minors, 14 years of age or older, may consent to outpatient mental
health services without parental or legal guardian consent, knowledge or participation, after
consulting with a licensed mental health professional and there is agreement on confidentiality
for minor initiated services.
Attached is a signed agreement that states the minor received mental health counseling which
included a discussion on confidentiality, and the minor and the licensed mental health
professional agree that the minor's mental health services should not be disclosed to the minor's
parents/legal guardian for the period of time specified in the agreement.
Clickortapheretoentertext. is hereby notifying the minor's health plan that the minor's self-
initiated mental health services should not be disclosed to the minor's parent(s)/legal guardian
through the health plan's explanation of benefits or by any other means. Non-disclosure is
temporary and begins and ends according to the effective and expiration dates in the agreement
with the minor. Should the non-disclosure agreement be withdrawn, or should the nondisclosure
be extended, the mental health provider will notify the health plan with an updated agreement.
PLEASE ATTACH THIS NOTICE TO THE NON-DISCLOSURE
AGREEMENT BEFORE SENDING THE FORMS TO THE APPROPRIATE
HEALTH PLAN.
NON-DISCLOSURE OF MINOR-INITIATED MENTAL HEALTH CARE
AGREEMENT
Pursuant to §577-29, HRS, minors, 14 years of age or older, may consent to outpatient mental
health services without parental or legal guardian consent, knowledge or participation, after
consulting with a licensed mental health professional and there is agreement on confidentiality
for minor-initiated services.
Minor's Statement:
I am a minor and am 14 years of age or older. I am seeking mental health services without
consent, knowledge or participation of my parent/legal guardian. My mental health care
provider and I had a discussion and there was agreement, that it is in my best interests not to
involve my parents in my mental health treatment, at this time. I am requesting confidentiality of
my minor-initiated mental health service information and that this information not be disclosed
to my parent(s)/legal guardian through my health plan's explanation of benefits or by any other
means. I understand that I or my therapist may withdraw this agreement and this agreement is
temporary as specified by my therapist.
Minor’s Signature REQUIRED):
_________________________________________ Date: ______________
Printed name: ______________________ Date of birth: _______________
Licensed Mental Health Professional's Signature REQUIRED:
_________________________________________ Date: ______________
Printed name: __________________________________________
Agency or name of business: ______________________________
Phone number: _________________________________________
NPI #: ________________________________________________
Name of Mental Health Professional who conducted the client's "minor-initiated" initial
assessment (if applicable): _____________________________________________________
To be completed and dates initialed by the
minor's therapist
Nondisclosure Effective
Start Date: Click or tap to enter a date.
Nondisclosure
Expiration Date: Click or tap to enter a date.
Extension of Nondisclosure
Start Date: Click or tap to enter a date.
Extension of Nondisclosure
Expiration Date:Click or tap to enter a date.
Agreement Withdrawal Date: Clickortapto
enteradate.
