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St. Camillus Application Form

St. Camillus Authorization Agreement

St. Camillus Confidential Admission Medical Summary

ST. CAMILLUS / SAN CAMILLO* NOTICE OF PRIVACY PRACTICES

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.

Website Privacy Policy

Introduction

St. Camillus Health System, Inc. and its affiliates, (“St. Camillus”) is strongly committed to protecting the privacy of its customers and visitors. This privacy policy describes what information St. Camillus will collect from visitors such as yourself, and how we will use that information once it is collected.

What Websites Does This Policy Apply To?

This privacy policy applies to St. Camillus’ Website located at stcam.com (the “Website”).  It does not apply to any other websites, including those that have hypertext links to the Website or third-party websites that St. Camillus links to.  This policy does not apply to the practices of any third party, affiliate, or business partner that St. Camillus does not own or control, or those organizations or groups who associate themselves with St. Camillus.

Collection of Non-personal Data

If you browse the Website without purchasing any products or services, you do so anonymously.  We do not collect your e-mail address or other personal information.  We do log your IP address (the internet address of your computer) to tell us which parts of our Website you visit and how long you spend there.  We do not link your IP address to anything personally identifiable; however, we do track the state and/or country you are accessing the internet from, the date and time you visited and the type of computer, operating system and Web browser you are using.  Your browser supplies us with this information.  We use this information from our server logs to learn more about our visitors as a group, not about you as an individual.  The information helps us identify overall usage patterns and trends on the site.

Collection of Your Personal Information

St. Camillus’ website contains various forms where you can input information.  We will use this information to provide services and products to you.  We may use this information to provide you with information about the products and services we offer.  St. Camillus will not sell or share your name, address, e-mail address or other personal information with any other organization, except our service providers that provide products and services on this website.

Removing or Updating Personal Information

If you believe your personal information is not accurate, or if you would like us to delete personal information collected by St. Camillus through this Website, please contact us at j leveritt at stcam dot com or call 414-259-6333.

Disclosure of Your Personal Information

St. Camillus may disclose your personal information if required to do so by law or in the good-faith belief that such action is necessary to: (a) satisfy a legal order or comply with legal process; (b) defend the rights of St. Camillus or its affiliates or business partners; or (c) protect the personal safety of St. Camillus employees, agents, affiliates, business partners, customers or Website users.

Third-Party Services

The Website offers features and services that are administered or provided by third parties hired by St. Camillus.  To receive these services, you may be required to provide these third parties with personal information.  All such services are subject to separate terms and conditions established by our third-party providers, including separate privacy policies, which may be different than this privacy policy.

Credit Card Information

When you purchase products or services online through our website, we do not collect, access or store your credit card information.  All financial information, including credit card information, is sent directly to the third party that processes credit card transactions on St. Camillus’ behalf.

Security

This website has reasonable technical and organizational security measures in place to protect the loss, misuse or alteration of information under our control.  We cannot guarantee that unauthorized third parties will never be able to defeat those security measures.  Although we cannot guarantee that our systems are 100% secure 100% of the time, we periodically update our technology in order to improve the protection of customer information.  This website does not use a secure server to transmit sensitive data to and from our site.  However, our third-party service providers that collect financial data do use secure servers.  Be sure not to transmit any credit card or other financial or sensitive data through this website unless you have first verified that the data is being submitted to our third-party service provider’s secure server.

Governing Law and Jurisdiction

This Policy, and St. Camillus’ collection and use of customer information, shall be governed and interpreted in accordance with the laws of the United States and the State of Wisconsin.  Any disputes arising out of this Policy shall be adjudicated in a court of competent jurisdiction in the Eastern District of the State of Wisconsin.

Governing Language

Any translation of this Policy is done for local requirements and in the event of a dispute between the English and any non-English versions, the English version of this Privacy Policy shall govern.

St. Camillus Privacy Policy Changes

St. Camillus reserves the right to change its privacy policy at any time without prior notice. Any changes to the privacy policy will be posted on this page and will be effective immediately upon posting.