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For
Residents/Clients, Their Families & Other Contacts
For
Employees Participating in our Section 125 Plan Healthcare Reimbursement Account
ST.
CAMILLUS / SAN CAMILLO* NOTICE OF PRIVACY PRACTICES
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THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
USE AND DISCLOSURE OF
HEALTH INFORMATION
St. Camillus/San Camillo* (also referred to as “Facility”)
may
use your health information, that is, information that constitutes
protected health information as defined in the Privacy Rule of the
Administrative Simplification provisions of the Health Insurance
Portability and Accountability Act of 1996, for purposes of providing you
treatment, obtaining payment for your care and conducting health care
operations. Our Facility has
established a policy to guard against unnecessary disclosure of your
health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES
FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment.
St. Camillus/San Camillo may use your health information to provide
care to you and disclose your health information to others who provide
care to you, such as your attending physician and other health care
professionals who are involved in your care.
For example, physicians involved in your care will need information
about your symptoms in order to prescribe appropriate medications.
Our Facility also may disclose your health care information to
individuals outside of the Facility involved in your care including family
members, pharmacists, suppliers of medical equipment or other health care
professionals.
To Obtain Payment.
St. Camillus/San Camillo may include your health information in
invoices to collect payment from third parties for the care you may
receive from our Facility. For
example, the Facility may be required by your health insurer to provide
information regarding your health care status so that the insurer will
reimburse you or our Facility. St.
Camillus/San Camillo also may need to obtain prior approval from your
insurer and may need to explain to the insurer your need for health care
and the services that will be provided to you.
To Conduct Health Care
Operations.
St. Camillus/San Camillo may use and disclose health information
for its own operations in order to facilitate the function of our Facility
and as necessary to provide quality care to all of the Facility's
residents. Health care
operations include activities such as:
- Quality assessment and improvement activities.
- Activities
designed to improve health or reduce health care costs.
- Protocol
development, case management and care coordination.
- Contacting
health care providers and residents with information about treatment
alternatives and other related functions that don't include treatment.
-
Professional
review and performance evaluation.
-
Maintaining
logs of residents who temporarily leave the Facility.
-
Resident
recognition programs, such as Resident of the Month or internal newsletter
articles featuring residents
- Training
programs including those in which students, trainees or practitioners in
health care learn under supervision.
- Training
of non-health care professionals.
- Accreditation,
certification, licensing or credentialing activities.
- Review
and auditing, including compliance reviews, medical reviews, legal
services and compliance programs.
- Business
planning and development including cost management and planning related
analyses and formulary development.
- Business
management and general administrative activities of St. Camillus/San
Camillo.
-
Fundraising
for the benefit of St. Camillus/San Camillo and certain marketing
activities.
For example, our Facility may use your health information to evaluate its
staff performance, combine your health information with other Facility
residents in evaluating how to more effectively serve all of our
Facility's residents, disclose your health information to Facility staff
and contracted personnel for training purposes, use your health
information to contact you or your family as part of general fundraising
and community information mailings (unless you tell us you do not want to
be contacted).
For the Facility Directory. St. Camillus/San Camillo typically posts resident names outside the
entrances to resident rooms or apartments.
St. Camillus/San Camillo may disclose certain information
about you including your name, your general health status, your religious
affiliation and where you are located in a facility directory while you
are in our Facility. The
Facility may disclose this information to people who ask for you by name.
However, religious affiliation will only be disclosed to clergy.
If you do not want our Facility to include your information in the
directory, you must notify:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
For Fundraising
Activities.
St. Camillus/San Camillo may use information about you including
your name, address and telephone number to contact you or your family to
raise money for our Facility. If
you do not want the Facility to contact you or your family, you must
notify the St. Camillus Foundation Director (414-259-8335) and indicate
that you do not wish to be contacted.
For Treatment Alternatives.
St. Camillus/San Camillo may use and disclose your health
information to tell you about or recommend possible treatment options or
alternatives that may be of interest to you.
THE FOLLOWING IS A
SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR
HEALTH INFORMATION MAY BE USED AND DISCLOSED WITHOUT YOUR WRITTEN CONSENT
OR AUTHORIZATION:
When Legally Required.
St. Camillus/San Camillo will disclose your health information when
it is required to do so by any Federal, State or local law.
When There Are Risks to Public Health.
St. Camillus/San Camillo may disclose your health information for
the following public activities and purposes:
- To
prevent or control disease, injury or disability, report disease, injury,
vital events such as birth or death and the conduct of public health
surveillance, investigations and interventions.
- To
report adverse events, product defects, to track products or enable
product recalls, repairs and replacements and to conduct post-marketing
surveillance and compliance with requirements of
the Food and Drug Administration.
- To
notify a person who has been exposed to a communicable disease or who may
be at risk of contracting or spreading a disease.
- To
an employer about an individual who is a member of the workforce as
legally required.
To Report Abuse,
Neglect Or Domestic Violence.
St. Camillus/San Camillo is allowed to notify government
authorities if our Facility believes a resident is the victim of abuse,
neglect or domestic violence. Our Facility will make this disclosure only when
specifically required or authorized by law or when the resident agrees to
the disclosure.
To Conduct Health
Oversight Activities.
St. Camillus/San Camillo may disclose your health information to a
health oversight agency for activities including audits; civil,
administrative or criminal investigations; inspections; licensure or
disciplinary action. The
Facility, however, may not disclose your health information if you are the
subject of an investigation and the investigation does not arise out of
and is not directly related to your receipt of health care or public
benefits.
In Connection With
Judicial And Administrative Proceedings.
As permitted or required by State law, St. Camillus/San Camillo may
disclose your health information in the course of any judicial or
administrative proceeding in response to an order of a court or
administrative tribunal as expressly authorized by such order or in
response to a subpoena, discovery request or other lawful process, but
only when the Facility makes reasonable efforts to either notify you about
the request or to obtain an order protecting your health information.
For Law Enforcement
Purposes.
As permitted or required by State law, St. Camillus/San Camillo may
disclose your health information to a law enforcement official for certain
law enforcement purposes, including, under certain limited circumstances,
if you are a victim of a crime or in order to report a crime.
To Coroners And
Medical Examiners.
St. Camillus/San Camillo may disclose your health information to
coroners and medical examiners for purposes of determining your cause of
death or for other duties, as authorized by law.
To Funeral Directors.
St. Camillus/San Camillo may disclose your health information to
funeral directors consistent with applicable law and if necessary, to
carry out their duties with respect to your funeral arrangements.
If necessary to carry out their duties, the Facility may disclose
your health information prior to and in reasonable anticipation, of your
death.
For Organ, Eye Or
Tissue Donation.
St. Camillus/San Camillo may use or disclose your health
information to organ procurement organizations or other entities engaged
in the procurement, banking or transplantation of organs, eyes or tissue
for the purpose of facilitating the donation and transplantation.
For Research Purposes.
St. Camillus/San Camillo may, under very select circumstances, use
your health information for research.
Before the Facility discloses any of your health information for
such research purposes, the project will be subject to an extensive
approval process. Our
Facility will almost always request your written authorization before
granting access to your individually identifiable health information.
In the Event of A
Serious Threat To Health Or Safety.
St. Camillus/San Camillo may, consistent with applicable law and
ethical standards of conduct, disclose your health information if our
Facility, in good faith, believes that such disclosure is necessary to
prevent or lessen a serious and imminent threat to your health or safety
or to the health and safety of the public.
For Specified
Government Functions.
In certain circumstances, the Federal regulations authorize our
Facility to use or disclose your health information to facilitate
specified government functions relating to the military and veterans,
national security and intelligence activities, protective services for the
President and others, medical suitability determinations and inmates and
law enforcement custody.
For Worker's
Compensation.
St. Camillus/San Camillo may release your health information for
worker's compensation or similar programs.
AUTHORIZATION TO USE
OR DISCLOSE HEALTH INFORMATION
Other than is stated above, St. Camillus/San Camillo will not
disclose your health information other than with your written
authorization. If you or your
representative authorizes our Facility to use or disclose your health
information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH
RESPECT TO YOUR HEALTH INFORMATION
You have
the following rights regarding your health information that St.
Camillus/San Camillo maintains:
Right to Request
Restrictions.
You may request restrictions on certain uses and disclosures of
your health information. You
have the right to request a limit on our Facility's disclosure of your
health information to someone who is involved in your care or the payment
of your care. However, our
Facility is not required to agree to your request.
If you wish to make a request for restrictions, please contact one
of the following individuals:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
Right to Receive
Confidential Communications.
You have the right to request that our Facility communicates with
you in a certain way. For example, you may ask that St. Camillus/San Camillo only
conduct communications pertaining to your health information with you
privately with no other family members present. Our Facility will not request that you provide any reasons
for your request and will attempt to honor your reasonable requests for
confidential communications. If
you wish to receive confidential communications, please contact one of the
following individuals:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
Right to Inspect and
Copy Your Health Information.
You have the right to inspect and copy your health information,
including billing records. If you request a copy of your health information, our
Facility will charge a reasonable fee for copying and assembling costs
associated with your request. A
request to inspect and copy records containing your health information may
be made to:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program Director at 414-258-2418
Right to Amend Your
Health Information.
You or your representative have the right to request that St.
Camillus/San Camillo amend your records, if you believe your health
information records are incorrect or incomplete.
That request may be made as long as the information is maintained
by our Facility. A request
for an amendment of records must be made in writing to:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
St. Camillus/San Camillo may deny the request if it is not in writing or
does not include a reason for the amendment.
The request also may be denied if your health information records
were not created by our Facility, if the records you are requesting are
not part of the Facility's records, if the health information you wish to
amend is not part of the health information you or your representative are
permitted to inspect and copy, or if, in the opinion of our Facility, the
records containing your health information are accurate and complete.
Right to an Accounting.
You or your representative have the right to request an accounting
of disclosures of your health information made by St. Camillus/San Camillo
for certain purposes, which may include disclosures authorized by law and
disclosures made for research. The
request for an accounting must be made in writing to:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
The request should specify the time period for the accounting starting on
April 14, 2003. Accounting
requests may not be made for periods of time in excess of six (6) years.
St. Camillus/San Camillo will provide the first accounting you
request during any 12-month period without charge.
Subsequent accounting requests may be subject to a reasonable
cost-based fee.
Right
to a Paper Copy of this Notice.
You or your representative have a right to a separate paper copy of
this Notice at any time even if you or your representative have received
this Notice previously. You
or your representative may also obtain a copy of the current version of
our Facility's Notice at its Web site, www.stcam.com.
To obtain a separate paper copy, please contact:
Independent living residents: Program
Director at 414-259-6300
Assisted living residents:
Program Director at 414-259-3784
Nursing home residents:
Administrator at 414-258-1814
Home health care clients: Program
Director at 414-258-2418
DUTIES OF FACILITY
St. Camillus/San Camillo is required by law to maintain the privacy of
your health information and to provide to you and your representative this
Notice of its duties and privacy practices.
Our Facility is required to abide by the terms of this Notice as
may be amended from time to time. Our
Facility reserves the right to change the terms of its Notice and to make
the new Notice provisions effective for all health information that it
maintains. If the Facility
changes its Notice, St. Camillus/San Camillo will provide a copy of the
revised Notice to you or your appointed representative. You or your representative have the right to express
complaints to our Facility and to the Secretary of Health and Human
Services if you or your representative believe that your privacy rights
have been violated. Our
Facility encourages you to express any concerns you may have regarding the
privacy of your information. You
will not be retaliated against in any way for filing a complaint.
Any complaints to Facility should be made in writing to the:
St. Camillus Privacy Officer at 414-259-3775.
CONTACT PERSON
Our Facility has designated the St. Camillus Privacy Officer as its
contact person for all issues regarding resident privacy and your rights
under the Federal privacy standards.
You may contact this person at:
Privacy Officer
St. Camillus
10101 W. Wisconsin Avenue
Wauwatosa, WI 53226
414-259-3775
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
Privacy Officer
St. Camillus
10101 W. Wisconsin Avenue
Wauwatosa, WI 53226
414-259-3775
*NOTE: The
names “St. Camillus” and “San Camillo” used in this document
collectively refer to the corporate entities: San Camillo, Inc., St. Camillus Health System, Inc., Order
of St. Camillus Foundation, Inc., St. Camillus Health Center, Inc., and
Camillian Ministries, Inc.
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Printed 3/14/03
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St.
Camillus Section 125 Plan
PRIVACY
NOTICE FOR
HEALTHCARE
REIMBURSEMENT ACCOUNT
THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
THIS
NOTICE APPLIES TO THE SECTION 125 HEALTH CARE REIMBURSEMENT PLAN SPONSORED BY
ST. CAMILLUS/SAN CAMILLO. IF
YOU PARTICIPATE IN AN INSURED BENEFIT PROGRAM, YOU WILL RECEIVE A SEPARATE
NOTICE DIRECTLY FROM THE INSURER.
This
Notice is effective April 14, 2004 (or such later date permitted by law).
INTRODUCTION
We at St. Camillus/San Camillo* understand that medical information about you is
personal. A federal law called HIPAA requires that health Plan and health care
providers protect the privacy of certain medical information. This Notice covers
the medical information practices of the St.
Camillus/San Camillo sponsored group health plan (the “Plan”).
This Notice is intended to inform you, in a summary fashion, of your rights
under the privacy provisions of HIPAA and the HIPAA obligations imposed on the St.
Camillus/San Camillo sponsored Plan.
If
you have general questions about your medical claims information maintained by
the Plan, call the privacy contact listed on the last page of this Notice for
your benefit option(s). For questions about medical information associated with
Section 125 plan eligibility or claims appeal information maintained by the St.
Camillus/San Camillo Plan, contact the St. Camillus/San Camillo Human Resources
office at the number listed on the last page of this Notice.
Do not contact the St. Camillus/San Camillo Human Resources office for
questions about an Insured Benefit (such as health or dental insurance claims);
instead, contact the health or dental plan representative directly.
Only
health information that may specifically identify you and
is used or disclosed by the Plan is protected by HIPAA. This health information
is called “protected health information” and we refer to it throughout this
Notice as “PHI.” Health information that St. Camillus/San Camillo receives
about you as an employer is not PHI. Thus,
your sick leave records, FMLA leave information, drug testing results,
workers’ compensation files, disability, life insurance and OSHA records are
not PHI and are not covered by this Notice.
If you have a question about such employment information, do not contact
the Plan; contact the St. Camillus/San Camillo Occupational Health RN.
From time to time, the Plan may provide St. Camillus/San Camillo with
summarized information, in order to obtain competitive bids, modify, amend, or
terminate the plan. This type of summarized information is also not considered
PHI.
Third
parties assist the Plan in administering your health benefits (e.g., Humana,
Dental Blue, etc. - see the last page of this Notice for a full list of the
benefit administrators). These
entities keep and use most of the medical information maintained by the Plan,
such as information about your health condition, the heath care services you
receive and the payments for such services. They use this information to process
your benefit claims. They are
required to use the same privacy protections as the Plan.
The
members of the departments defined by St.
Camillus/San Camillo and identified below who assist with administration
of the Plan have limited access to medical information about you.
This information is generally limited to: (1) whether you are enrolled in
the Plan or are eligible; (2) the family members you cover under the Plan; (3)
the amount you contribute for your health care coverage, and (4) information
about certain claims, claim denials, and appeals.
Remember,
the Plan does not maintain all of your
medical information. Your health care providers (e.g., doctors, hospitals) also
maintain some of your information. You should ask your health care providers
directly if you have any questions about medical information maintained by them.
HOW
THE PLAN MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
This section describes how the Plan uses and discloses medical information to
administer benefits. Please note that this Notice does not list every
use or disclosure, instead it gives examples of the most common uses and
disclosures.
Primary
Uses and Disclosures of PHI
·
The Plan may disclose your PHI so that your doctors, dentists,
pharmacies, hospitals and other health care providers may provide you with medical
treatment. The Plan also may send your health care information to doctors
for patient safety or other treatment-related reasons.
·
The Plan may use and disclose your PHI for benefit
payment such as to see if you are eligible for benefits, to calculate your
benefits under the Plan, to pay your health care providers for treating you, to
calculate your co-pays and co-insurance amounts, to decide claims appeals and
inquiries, or to coordinate coverage. For
example, the Plan may disclose information about your medical history to a
physician (including your physician) to determine whether a particular treatment
is experimental, investigational, or medically necessary or to decide if the
Plan will cover the treatment. The Plan may also share medical information with a
utilization review or pre-certification service provider.
Likewise, the Plan may share medical information with another entity to
coordinate payment of your benefits (e.g., under your spouse’s plan). The Plan
will also share your information to assist with subrogation of your claims.
·
The Plan may use and disclose PHI about you for additional related health
care operations necessary to operate the Plan.
For example, the Plan may use PHI in connection with: underwriting and
soliciting bids from potential insurance carriers; merger and acquisition
activities, setting premiums; deciding employee premium contributions;
submitting claims to the Plan’s stop-loss (or excess loss) carrier; conducting
or arranging for medical review; legal services; audit services; and fraud and
abuse detection programs. The Plan also may use your PHI for administrative
activities such as business planning and development, cost management, business
management and conducting quality assessment and improvement activities.
·
The Plan may use your
medical information to contact you or give you information about treatment
alternatives or other health-related benefits and services that may be of
interest to you. The Plan may disclose your medical information to its third
party administrators to assist in these activities.
Other
Uses and Disclosures of Your PHI
·
The Plan is required to disclose your PHI to the Secretary of the U.S.
Department of Health and Human Services if the Secretary is investigating or
determining compliance with HIPAA.
·
The Plan will disclose PHI about you when required to do so by federal,
state or local law.
·
The Plan may use and disclose PHI about you when necessary to prevent a
serious threat to your health and safety or the health and safety of the public
or another person.
·
If you are an organ donor, the Plan may release your PHI to organizations
that handle organ procurement or organ, eye or tissue transplantation or to an
organ donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
·
If you are a member of the armed forces, the Plan may release your PHI as
required by military command authorities.
·
The Plan may release your PHI for workers' compensation or similar
programs.
·
The Plan may disclose your PHI for public health activities such child
abuse and neglect, threats to public health and safety, and national security.
·
The Plan may disclose your PHI to a health oversight agency for
activities authorized by law (e.g., audits, investigations, inspections, and
licensure).
·
If you are involved in a lawsuit or a dispute, the Plan may disclose your
PHI in response to a court or administrative order.
The Plan may also disclose your PHI in response to a subpoena, discovery
request, or other lawful process to someone else involved in the dispute, but
only if efforts have been made to tell you about the request or to obtain an
order protecting the information requested.
·
The Plan may release your PHI if asked to do so by a law enforcement
official.
·
The Plan may release medical information to a coroner or medical
examiner.
·
The Plan may release your PHI to authorized federal officials for
intelligence, counterintelligence, and other national security activities
authorized by law.
·
If you are an inmate of a correctional institution or under the custody
of a law enforcement official, the Plan may release your PHI to the correctional
institution or law enforcement official.
·
Using its best judgment, the Plan may disclose your PHI to a family
member, other relative, close friend or other personal representative.
Such a use will be based on how involved the person is in your care,
or payment that relates to that care. The
Plan may release claims payment information to spouses, parents, or guardians.
Other
uses and disclosures of your PHI that are not described above will be made only
with your written authorization. If
you authorize the Plan to use or disclose your PHI, you may revoke the
authorization at any time in writing. However, your revocation will only stop
future uses and disclosures that are made after the Plan receives your
revocation. It will not have any affect on the prior uses and disclosures of
your PHI.
The
privacy laws of a particular state or other federal laws might impose a stricter
privacy standard. If these stricter laws apply and are not superseded by federal
ERISA preemption, the Plan will comply with the stricter law.
YOUR
RIGHTS REGARDING YOUR PHI.
You
have the following rights regarding PHI the Plan has about
you:
·
You have the right to inspect and copy your PHI that may be used to make
decisions about your benefits. To
inspect and copy your PHI that may be used to make decisions about you, you must
submit your request in writing to the appropriate privacy contact listed below.
If you request a copy of this information, the Plan may charge a fee for the
costs of copying, mailing or other supplies associated with your request.
The Plan may deny your request to inspect and
copy in certain very limited circumstances. HIPAA
provides several important exceptions to your right to access your PHI.
For example, you will not be permitted to access psychotherapy notes or
information compiled in anticipation of, or for use in, a civil, criminal or
administrative action or proceeding. The
Plan will not allow you to access your PHI if these or any of the exceptions
permitted under HIPAA apply. If you are denied access to your PHI, you may request a review of the
denial.
·
If you feel that PHI the Plan has about you is incorrect
or incomplete, you may ask the Plan to amend the information. You have the right
to request an amendment for as long as the information is kept by or for the
Plan. To request an amendment, you must submit your request in writing to
the appropriate privacy contact listed below. Your request must list the specific PHI you want amended and
explain why it is incorrect or
incomplete.
The
Plan may deny your request for an amendment if it is not in writing or does not
list why it is incorrect or incomplete. In
addition, the Plan may deny your request if you ask the Plan to amend
information that:
·
Is
not part of the medical information kept by or for the Plan;
·
Was
not created by the Plan or its third party administrators;
·
Is
not part of the information which you would be permitted to inspect and copy; or
·
Is
accurate and complete.
If
the Plan denies your request, they must provide you a written explanation for
the denial and an explanation of your right to submit a written statement
disagreeing with the denial.
·
You have the right to request an "accounting of disclosures" of
your PHI - a list of disclosures the Plan has made of your PHI. This list will
not include disclosures to you or your personal representative, ones you
authorized in writing, or disclosures made for treatment, payment, or health
care operations. The Plan will not include in your accounting any of the
disclosures for which there is an exception under HIPAA.
To
request this list of disclosures you must submit your request in writing to the
appropriate privacy contact listed below. Your
request must state the time period for the disclosures, e.g., all disclosure
between July 2004 and August 2004. The time period cannot be longer than six
years nor include dates before April 14, 2003.
You
may request one accounting in any 12-month period free of charge. The Plan will
impose a fee for each subsequent request within the 12-month period. The Plan
will notify you of the cost involved and you may choose to withdraw or modify
your request at that time before any costs are incurred.
·
You have the right to request that the Plan communicates with you about
medical matters in a certain way or at a certain location.
For example, you can ask that the Plan only contacts you at work or by
mail. The Plan will only
accommodate these requests if you inform them that disclosure of your PHI could
endanger you. To request
confidential communications, you must submit your request in writing to the
appropriate privacy contact listed below. Your request must specify how or where
you wish to be contacted.
·
You may also request that
the Plan discloses your PHI to your personal representative. A personal
representative is an individual you designate to act on your behalf and make
decisions about your medical care. If you want the Plan to disclose your PHI to
your personal representative, submit a written statement giving the Plan
permission to release your PHI to your personal representative and documentation
that this individual qualifies as your personal representative under state law,
such as a power of attorney. Submit this request in writing to the appropriate
privacy contact listed below.
CHANGES
TO THIS NOTICE
The
Plan has the right to change this Notice at any time. The Plan also has the right to make the revised or changed
Notice effective for medical information the Plan already has about you as well
as any information received in the future.
The Plan will post a copy of the current Notice on the company’s
website. All Notices will contain
the effective date on the first page.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint
with the Plan or with the Secretary of the Department of Health and Human
Services. To file a complaint with
the Plan, contact the St. Camillus/San Camillo Privacy Official at the address
listed below. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
CONTACT
INFORMATION:
ALTHOUGH
YOU WILL RECEIVE A SEPARATE PRIVACY NOTICE FROM THE INSURERS OF OUR INSURED
BENEFIT OPTIONS, THE CONTACTS FOR THE VARIOUS INSURED BENEFIT OPTIONS ARE AS
FOLLOWS:
Health
plan privacy contact: Humana Privacy
Office
Dental
plan privacy contact: Privacy Officer
- Blue Cross/Blue Shield of Wisconsin
THE
St. Camillus/San Camillo PRIVACY OFFICIAL (SOLELY FOR FILING COMPLAINTS)
INFORMATION IS:
Human
Resources Director
10101 W. Wisconsin Ave., Wauwatosa, WI
53226
414-259-3775
(telephone)
414-259-7767 (fax)
*NOTE:
For purposes of this agreement, the abbreviated names “St. Camillus”
and “San Camillo” shall encompass the following corporations:
St. Camillus Health System, Inc.; St. Camillus Health Center, Inc.; San
Camillo, Inc.; St. Camillus Communities, Inc.; St. Camillus Ministries, Inc.;
and Order of St. Camillus Foundation, Inc.
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