THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW ITvCAREFULLY.
Health information which Tunnel Vision Recovery, LLC and its employees andagents (“Tunnel Vision” or “we”) receive and/or create about you, personally,relating to your past, present, or future health, treatment, or payment forhealth care services, is “protected health information” under the Federal lawknown as the Health Insurance Portability and Accountability Act (“HIPAA”),45 C.F.R. Parts 160 and 164. The confi dentiality of substance abuse patientrecords maintained by Tunnel Vision is protected by other Federal law andregulations: 42 U.S.C. § 290dd-2 and 42 C.F.R. Part 2. Generally, Tunnel Visionmay not say to a person outside of Tunnel Vision that you are a patient ofTunnel Vision, or disclose any information identifying you as a substanceabuser, or use or disclose any other protected health information except inlimited circumstances as permitted by Federal law and described below. Yourhealth information is further protected as confi dential by Sections 394.4615,397.501(7) and 456.057 of the California Statutes.
This Notice describes how Tunnel Vision protects personal health information(otherwise referred to as “protected health information”) we have about you,and how we may use and disclose this information. This Notice also describesyour rights with respect to protected health information and how you canexercise those rights. Clear Life is required by law to notify you of our legalduties and privacy practices, including any changes to our policies. TunnelVision must comply with the terms of the notice currently in eff ect butreserves the right to change the terms of its notice and to make the newnotice provisions eff ective for all protected health information maintained byTunnel Vision. If Tunnel Vision does change its notice, you will be notifi ed bymail to your last address on record with Tunnel Vision
Uses and disclosures that may be made of your protected health information:
Internal Communications:
Your protected health information will beused between and among Tunnel Vision staff who have a need for theinformation in connection with our duty to diagnose, treat, or refer youfor substance abuse treatment. This means that your protected healthinformation may be shared between or among Tunnel Vision personnelfor treatment, payment or health care operation purposes. For example:Two or more providers within Tunnel Vision may consult with eachother regarding your best course of treatment. Tunnel Vision mayshare your protected health information in a billing eff ort to receivepayment for health care services rendered to you. Additionally, yourprotected health information may be discussed within Tunnel Vision inan eff ort to improve the overall quality of care provided by ourprogram. Your protected health information will not be re-disclosed byTunnel Vision personnel, except as is otherwise permitted herein.
Qualified Service Organizations and/or Business Associates:
Someor all of your protected health information may be subject to disclosurethrough contracts for services with qualifi ed service organizationsand/or business associates, outside of Tunnel Vision, that assist TunnelVision in providing health care. Examples of qualifi ed serviceorganizations and/or business associates include billing companies,data processing companies, or companies that provide administrativeor specialty services. To protect your health information, we requirethese qualifi ed service organizations and/or business associates tofollow the same standards held by Tunnel Vision through termsdetailed in a written agreement.
Medical Emergencies:
Your health information may be disclosed tomedical personnel in a medical emergency, when there is immediatethreat to the health of an individual, and when immediate medicalintervention is required.
To Researchers:
Under certain circumstances, Tunnel Vision mayuse and disclose your protected health information for researchpurposes. For example, a research project may involve comparing thehealth and recovery of all patients who received one test or treatmentto those who received another test or treatment for the samecondition. All research projects, however, must be approved by anInstitutional Review Board, or other privacy review board as permittedwithin the regulations, that has reviewed the research proposal and
established protocols to ensure the privacy of your protected healthinformation.
To Auditors and Evaluators:
Tunnel Vision may disclose protectedhealth information to regulatory agencies, funders, third-party payers,and peer review organizations that monitor substance abuse programsto ensure that Tunnel Vision is complying with regulatory mandatesand is properly accounting for and disbursing funds received.
Authorizing Court Order:
Tunnel Vision may disclose yourprotected health information pursuant to an authorizing court order.This is a unique kind of court order in which certain applicationprocedures have been taken to protect your identity, and in which thecourt makes certain specifi c determinations as outlined in the Federalregulations and limits the scope of the disclosure.
Crime on Program Premises or Against Program Personnel:
TunnelVision may disclose a limited amount of protected health informationto law enforcement when a patient commits or threatens to commit acrime on the program premises or against program personnel.
Reporting Suspected Child Abuse and Neglect:
Tunnel Vision mayreport suspected child abuse or neglect as mandated by state law.
As Required By Law:
Tunnel Vision will disclose protected healthinformation as required by state law in a manner otherwise permittedby federal privacy and confi dentiality regulations.
Appointment Reminders:
Tunnel Vision reserves the right tocontact you, in a manner permitted by law, with appointment remindersor information about treatment alternatives and other health relatedbenefi ts that may be appropriate to you.
Other Uses and Disclosure of Protected Health Information:
Other uses and disclosures of protected health information not covered bythis notice will be made only with your written authorization or that of your legal representative. If you (or your legal representative)authorize us to use or disclose protected health information about you,you (or your legal representative) may revoke that authorization at anytime, except to the extent that we have already taken action relying onthe authorization.
Your rights regarding protected health information we maintain about you:
Right to Inspect and Copy:
In most cases, you have the right toinspect and obtain a copy of the protected health information thatTunnel Vision maintains about you. To inspect and copy your protectedhealth information, you must submit your request in writing to TunnelVision. In order to receive a copy of your protected health information,you may be charged a fee for the photocopying, mailing, or other costsassociated with your request. In some very limited circumstancesTunnel Vision may, as authorized by law, deny your request to inspectand obtain a copy of your protected health information. You will benotifi ed of a denial to any part or parts of your request. Some denials,by law, are reviewable, and you will be notifi ed regarding theprocedures for invoking a right to have a denial reviewed. Otherdenials, however, as set forth in the law, are not reviewable. Eachrequest will be reviewed individually, and a response will be provided toyou in accordance with the law.
Right to Amend Your Protected Health Information:
If you believethat your protected health information is incorrect or that an importantpart of it is missing, you have the right to ask Tunnel Vision to amendyour protected health information while it is kept by or for TunnelVision. You must provide your request and your reason for the requestin writing, and submit it to Tunnel Vision. Tunnel Vision may deny yourrequest if it is not in writing or does not include a reason that supportsthe request. In addition, Tunnel Vision may deny your request if youask Tunnel Vision to amend protected health information that TunnelVision believes:
1. Is accurate and complete;
2. Was not created by Tunnel Vision, unless the person or entity thatcreated the protected health information is no longer available to makethe amendment;
3. Is not part of the protected health information kept by or for TunnelVision; or
4. Is not part of the protected health information which you would bepermitted to inspect and copy.
If your right to amend is denied, Tunnel Vision will notify you of the denialand provide you with instructions on how you may exercise your right tosubmit a written statement disagreeing with the denial and/or how you may request that your request to amend and a copy of the denial be kept togetherwith the protected health information at issue, and disclosed together withany further disclosures of the protected health information at issue.
Right to an Accounting of Disclosures:
You have the right torequest an accounting or list of the disclosures that Tunnel Vision hasmade of protected health information about you. This list will notinclude certain disclosures, as set forth in the HIPAA regulations,including disclosures made for treatment, payment, or health careoperations within Tunnel Vision, disclosures made pursuant to yourauthorization or disclosures made directly to you. To request this list,you must submit your request in writing to this off ice. Your requestmust state the time period from which you want to receive a list ofdisclosures. The time period may not be longer than six years, and maynot include dates before April 14, 2003. Your request should indicate inwhat form you want the list (for example, on paper or electronically).The fi rst list you request within a 12-month period will be free. We maycharge you for responding to any additional requests. We will notifyyou of the cost involved and you may choose to withdraw or modifyyour request at that time before any costs are incurred.
Right to Request Restrictions:
You have the right to request arestriction or limitation on the protected health information TunnelVision is permitted to use or disclose about you for treatment, paymentor health care operations within Tunnel Vision. While we will consideryour request, we are not required to agree to it. If we do agree to it, wewill comply with your request, except in emergency situations whereyour protected health information is needed to provide you withemergency treatment. We will not agree to restrictions on uses ordisclosures that are legally required, or those which are legallypermitted and which we reasonably believe to be in the best interest ofyour health.
Right to Request Confi dential Communications:
You have the rightto request that we communicate with you about protected healthinformation in a certain manner or at a certain location. For example,you can ask that we only contact you at work or by mail. To requestconfi dential communications, you must make your request in writing toTunnel Vision, and specify how or where you wish to be contacted. Wewill accommodate all reasonable requests.
Right to File a Complaint:
Violation of the Federal law andregulations by Tunnel Vision is a crime. If you believe your privacyrights have been violated, you may fi le a complaint with Tunnel Visionor with the Secretary of the Dpartment of Health Care Services. To fi lea complaint with Tunnel Vision, please contact 347-472-2003. You willnot be penalized or otherwise retaliated against for fi ling a complaint. Ifyou have questions as to how to fi le a complaint please contact TunnelVision at 347-472-2003.
To receive additional information:
For further explanation of this Notice you may contact 347-472-2003.
Availability of Notice of Privacy Practices:
This notice will be posted where registration occurs [or other prominentphysical location Tunnel Vision decides to post the notice]. You have a right to receive a copy of this notice, and all individuals receiving care will be given a hard copy.
