Superior Vision Services, Inc.
Privacy Notice
This notice is being sent to you to protected health information we health information in a
ensure our compliance with the maintain. Revised notices will be confidential manner.
Health Insurance provided to you by mail.
Portability and Accountability 3. Information We
Act of 1996. SVS supports 2. Statement of Your Collect About You
the effort to protect patient Rights
confidentiality and the security of We collect the following categories
individual health You have a right to know how of information about you from the
information. we may use or disclose your following sources:
personal health information. This • Information that we obtain
This notice describes how medical notice informs you of those uses directly from you, in
information about you may be and disclosures. There are conversations or on
used and disclosed and how you certain uses and disclosures of applications or other forms
can get access to this information. your personal health information that you fill out.
Please review it carefully. that we are permitted or required • Information that we obtain as a
to make by law without your result of our transactions with
This notice is effective April 13, permission. For all other you.
2003. uses and disclosures, we first • Information that we obtain
must obtain your permission. In from your medical records or
1. Statement of Our Duties addition, you have the following from medical professionals.
rights: • Information that we obtain
We are committed to maintaining • The right to request that we from other entities, such as
the privacy of your personal health place additional restrictions health care providers or other
information and complying with all on our uses and disclosures insurance companies, in order
state and federal privacy laws. The of your personal health to service your policy or carry
purpose of this Privacy Notice is to information. However, we out other insurance-related
inform you of our privacy practices are not obligated to agree to needs.
and legal duties. We are required to: impose any such additional
• maintain the privacy of restrictions.
protected health information;
4. Permissible Uses and
• The right to access, inspect
• provide you with this notice of
Disclosures of Protected
and copy the protected
our legal duties and privacy information pertaining to Information
practices with respect to your you that we maintain in our
health information; files about you, and the • To Carry Out Treatment
• abide by the terms of this right to have us correct or Functions. We may use or
notice; amend any information that disclose your health
• •notify you if we are unable to we create in error. Requests information without your
agree to a request restriction to access or amend your permission in order for health
on how your information is health information should care providers to provide you
used or disclosed; be sent to the contact with treatment.
• accommodate reasonable person and address • To Carry Out Payment
requests that you may make to provided in Section 8. Functions. We may use or
communicate health • The right to receive an disclose your health
information by alternative accounting of the information without your
means or at alternative disclosures of your personal permission to carry out
locations; and health information that we activities relating to
• obtain your written make for purposes other reimbursing you for the
authorization to use or disclose than activities related to provision of health care,
your health information for your treatment, or our obtaining premiums,
reasons other than those payment functions or other determining coverage, and
identified in this notice and health care operations. providing benefits under the
permitted under law. • The right to request that policy of insurance that you
We reserve the right to change our you receive are purchasing. Such functions
information practices and to make communications of personal may include reviewing health
the new provisions effective for all care services with respect to
medical necessity, coverage
Superior Vision Services
11101 White Rock Rd., Suite 150
Rancho Cordova, CA 95670
Superior Vision Services Privacy Notice
under the policy, protected health
appropriateness of care, or information will be made
justification of charges only with your written
• To Carry Out Certain permission, and you may 8. Contact Person For
Operations Relating To Your revoke any permission that Filing Complaint or
Benefit Plan. We also may you give us at any time.
Obtaining Further
use or disclose your protected
Information
health information without 5. Complaints About
your permission to carry out Misuse of Health If you have any questions or
certain limited activities Information complaints, please contact:
relating to your health
Kimberley Hess VP of Operations
insurance benefits, including You may complain either
reviewing the competence or directly to us or to the Secretary Superior Vision Services
qualifications of health care of Health and Human Services if 11101 White Rock Rd. Suite 150
professionals, conducting you believe that your rights Rancho Cordova, CA 95670
quality assessment activities, with respect to our protection of
amending, replacing or adding your health information have This privacy notice applies to the
benefits, and placing contracts been violated. You may file a following:
for stop-loss insurance or complaint with us by submitting SVS
reinsurance. a complaint in writing to the
• In Situations Permitted Or address shown in Section 8 that
Required By Law. We also includes as many details (such as Office for Civil Rights
may use or disclose your names and dates) as possible. U.S. Department of Health and
protected health information You will not be retaliated against Human Services
without your written in any way for filing a 200 Independence Avenue, S.W.
permission for other purposes complaint. Room 509F, HHH Building
permitted or required by law, Washington, D.C. 20201
including the following: 6. Our Practices Regarding OCR Hotlines-Voice: 1-800-368-
• As authorized by and to the Confidentiality and 1019
extent necessary to comply Security
with workers compensation or
other no-fault laws. We restrict access to nonpublic
• To a health oversight agency personal information about you
for activities including audits to those employees who need to
or civil, criminal or know that information in order
administrative proceedings. to provide products or services
• To a public health authority for to you. We maintain physical,
purposes of public health electronic, and procedural
activities (such as to the Food safeguards that comply with
and Drug Administration to federal regulations to guard your
report consumer product non public personal information.
defects).
• To a law enforcement official 7. Our Policy Regarding
for law enforcement purposes Dispute Resolution
or in response to a court order
or in the course of any judicial Any controversy or claim arising
or administrative proceeding. out of or relating to our privacy
• To organ procurement policy, or the breach thereof,
organizations, or to other shall be settled by arbitration in
entities for approved research the State of California, in
purposes. accordance with the rules of the
• To a government authority, American Arbitration
including a social service or Association, and judgment upon
protective services agency, the award rendered by the
authorized to receive reports of arbitrator(s) may be entered in
abuse, neglect or domestic any court having jurisdiction
violence. thereof.
• For Purposes For Which We
Have Obtained Your
Written Permission. All other
uses or disclosures of your
Superior Vision Services
11101 White Rock Rd., Suite 150
Rancho Cordova, CA 95670
The Superior Vision Plan is underwritten by ReliaStar Life Insurance Company. For that reason,
the HIPAA Privacy Notice for ReliaStar (ING Re) is also attached.
ING Re
Privacy Notice
This notice is being sent to
We reserve the right to change our 3. Information We Collect
you to ensure our compliance
information practices and to make the
with the Health Insurance
new provisions effective for all
About You
Portability and Accountability We collect the following categories of
Act of 1996. ING Re supports protected health information we
maintain. Revised notices will be information about you from the
the effort to protect patient
following sources:
confidentiality and the provided to you by mail.
security of individual health • Information that we obtain directly
information. 2. Statement of Your Rights from you, in conversations or on
applications or other forms that you
You have a right to know how we may
This notice describes how use or disclose your personal health
fill out.
medical information about you • Information that we obtain as a result
information. This notice informs you of
may be used and disclosed of our transactions with you.
and how you can get access those uses and disclosures. There are
• Information that we obtain from your
to this information. Please certain uses and disclosures of your
medical records or from medical
review it carefully. personal health information that we are
professionals.
permitted or required to make by law
• Information that we obtain from other
This notice is effective April without your permission. For all other
entities, such as health care providers
13, 2003. uses and disclosures, we first must
or other insurance companies, in
obtain your permission. In addition,
order to service your policy or carry
you have the following rights:
1. Statement of Our Duties • The right to request that we place
out other insurance-related needs.
We are committed to maintaining the additional restrictions on our uses and
privacy of your personal health
4. Permissible Uses and
disclosures of your personal health
information and complying with all Disclosures of Protected
information. However, we are not
state and federal privacy laws. The obligated to agree to impose any such Information
purpose of this Privacy Notice is to additional restrictions. • To Carry Out Treatment
inform you of our privacy practices and • The right to access, inspect and copy Functions. We may use or disclose
legal duties. We are required to: the protected information pertaining your health information without your
• maintain the privacy of protected to you that we maintain in our files permission in order for health care
health information; about you, and the right to have us providers to provide you with
• provide you with this notice of our correct or amend any information that treatment.
legal duties and privacy practices we create in error. Requests to access • To Carry Out Payment Functions.
with respect to your health or amend your health information We may use or disclose your health
information; should be sent to the contact person information without your permission
• abide by the terms of this notice; and address provided in Section 8. to carry out activities relating to
• notify you if we are unable to agree • The right to receive an accounting of reimbursing you for the provision of
to a request restriction on how your the disclosures of your personal health care, obtaining premiums,
information is used or disclosed; health information that we make for determining coverage, and providing
• accommodate reasonable requests purposes other than activities related benefits under the policy of insurance
that you may make to communicate to your treatment, or our payment that you are purchasing. Such
health information by alternative functions or other health care functions may include reviewing
means or at alternative locations; and operations. health care services with respect to
• obtain your written authorization to • The right to request that you receive medical necessity, coverage under the
use or disclose your health communications of personal health policy, appropriateness of care, or
information for reasons other than information in a confidential manner. justification of charges.
those identified in this notice and
permitted under law.
ING Re Privacy Notice
• To Carry Out Certain Operations • To a government authority,
7. Our Policy Regarding
Relating To Your Benefit Plan. We including a social service or
also may use or disclose your protective services agency,
Dispute Resolution
protected health information without authorized to receive reports of Any controversy or claim arising out of
your permission to carry out certain abuse, neglect or domestic violence. or relating to our privacy policy, or the
limited activities relating to your • For Purposes For Which We Have breach thereof, shall be settled by
health insurance benefits, including Obtained Your Written arbitration in Minneapolis, MN, in
reviewing the competence or Permission. All other uses or accordance with the rules of the
qualifications of health care disclosures of your protected health American Arbitration Association, and
professionals, conducting quality information will be made only with judgment upon the award rendered by
assessment activities, amending, your written permission, and any the arbitrator(s) may be entered in any
replacing or adding benefits, and permission that you give us may be court having jurisdiction thereof.
placing contracts for stop-loss revoked by you at any time.
insurance or reinsurance. 8. Contact Person For Filing
• In Situations Permitted Or 5. Complaints About Misuse of Complaint or Obtaining
Required By Law. We also may use Health Information Further Information
or disclose your protected health You may complain either directly to us If you have any questions or complaints,
information without your written or to the Secretary of Health and Human please contact:
permission for other purposes Services if you believe that your rights
permitted or required by law, with respect to our protection of your Jane Johnson
including the following: health information have been violated. HIPAA Privacy Officer
• As authorized by and to the extent You may file a complaint with us by ING Re/ ReliaStar Life Insurance
necessary to comply with workers submitting a complaint in writing to the Company
compensation or other no-fault laws. address shown in Section 8 that includes 20 Washington Avenue South
• To a health oversight agency for as many details (such as names and Route 4882
activities including audits or civil, dates) as possible. You will not be Minneapolis, MN 55401
criminal or administrative retaliated against in any way for filing a
proceedings. complaint. All products and services of ING Re are
• To a public health authority for provided by ReliaStar Life Insurance
purposes of public health activities 6. Our Practices Regarding Company.
(such as to the Food and Drug Confidentiality and Security
Administration to report consumer This privacy notice applies to the
We restrict access to nonpublic personal
product defects). following ING Companies:
information about you to those
• To a law enforcement official for ING Re
employees who need to know that
law enforcement purposes or in
information in order to provide products
response to a court order or in the
or services to you. We maintain * Products and services provided by
course of any judicial or
physical, electronic, and procedural ReliaStar Life Insurance Company
administrative proceeding.
safeguards that comply with federal
• To organ procurement
regulations to guard your nonpublic
organizations, or to other entities for
personal information.
approved research purposes.
ING Re
20 Washington Avenue South
Minneapolis, MN 55401