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St. CAMILLUS/SAN CAMILLO JOINT 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.

St. Camillus Health System, Inc. (hereinafter referred to as “St. Camillus/San Camillo”) and each of the following St. Camillus/San Camillo affiliates, together, designate themselves as a single Affiliated Covered Entity (“ACE”) for purposes of compliance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”): San Camillo, Inc., Order of St. Camillus Foundation, Inc., St. Camillus Skilled Nursing, Inc., and Camillian Ministries, Inc. Each of these entities, sites, locations and care providers will follow the terms of this Joint Notice. In addition, these entities, sites, locations and care providers may share medical information with each other for treatment, payment or health care operations related to the ACE.

St. Camillus/San Camillo also participates in an Organized Health Care Arrangement (“OHCA”) with other covered entities. This Joint Notice is jointly used by and jointly describes the practices of all participants within the OHCA, including, without limitation:

  • Any health care professional authorized to enter information into your chart.
  • All departments or units of St. Camillus/San Camillo.
  • Any member of a volunteer group we allow to help you while you are a resident of, or being treated at, a St. Camillus/San Camillo facility.
  • All employees, staff or other St. Camillus/San Camillo personnel.

Each of the above individuals or entities participating in the OHCA will follow the terms of this Joint Notice. In addition, these individuals or entities may share medical information with each other for treatment, payment or health care operations related to the OHCA.

St. Camillus/San Camillo is required by law to maintain the privacy of your health information, to provide to you (or your representative) this Joint Notice of our duties and privacy practices, and to notify you (or your representative) following a breach of your unsecured health information. St. Camillus/San Camillo is required to abide by the terms of our Joint Notice as may be amended from time to time. St. Camillus/San Camillo has the right to change the terms of our Joint Notice. Any revisions to this Joint Notice will be effective for all health information that St. Camillus/San Camillo has created or maintained in the past, and for any records that St. Camillus/San Camillo creates or maintains in the future. St. Camillus/San Camillo will post our current Joint Notice in a prominent location in our facility, as well as on our website, www.stcam.com.

USE AND DISCLOSURE OF HEALTH INFORMATION

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND THE PURPOSES FOR WHICH ST. CAMILLUS/SAN CAMILLO MAY USE OR DISCLOSE YOUR HEALTH INFORMATION:

To Provide Treatment
St. Camillus/San Camillo may use or disclose your health information to treat you and coordinate your care within St. Camillus/San Camillo. For example, your attending physician or other health care professionals involved in your care may use information about your symptoms in order to prescribe appropriate medications. St. Camillus/San Camillo may also disclose your health information to individuals outside of St. Camillus/San Camillo 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 use or disclose your health information to bill or collect payment from third parties for the services or items you receive from St. Camillus/San Camillo. For example, St. Camillus/San Camillo may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or St. Camillus/San Camillo. St. Camillus/San Camillo may also 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 or disclose your health information for our own operations in order to facilitate the functions of St. Camillus/San Camillo and as necessary to provide quality care to all of St. Camillus/San Camillo’s residents. For example, St. Camillus/San Camillo may use your health information to evaluate our staff performance, combine your health information with that of other St. Camillus/San Camillo residents to evaluate how we may more effectively serve all St. Camillus/San Camillo residents, disclose your health information to St. Camillus/San Camillo staff and contracted personnel for training purposes, or use your health information to contact you or your family as part of general community information mailings. St. Camillus/San Camillo may also disclose your health information to a health oversight agency performing activities authorized by law, such as investigations or audits. These agencies include governmental agencies that oversee the health care system, government benefit programs, and organizations subject to government regulation and civil rights laws. In addition, St. Camillus/San Camillo may disclose your health information to another health care provider subject to Federal privacy protection laws, as long as the provider has or has had a relationship with you and the information is for that provider’s health care operations.

For the St. Camillus/San Camillo Directory
If you are receiving care at a St. Camillus/San Camillo facility, unless you request otherwise, St. Camillus/San Camillo may disclose certain information about you (e.g., name, general health status and room number) that is contained in the St. Camillus/San Camillo directory to anyone who asks for you by name. In addition, if you provide your religious affiliation, it may be disclosed, but only to members of the clergy. St. Camillus/San Camillo also may list your name outside the entrance to your room or apartment. If you do not want St. Camillus/San Camillo to include any or some of your information in the St. Camillus/San Camillo directory or outside your room, you must notify the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing Residents: Administrator at 414‑258‑1814
Home Health Care Clients: Program Director at 414‑258‑2418.

For Fundraising Activities
In support of our charitable mission, St. Camillus/San Camillo may use information about you (e.g., demographic information, dates of health care provided, department of service information, treating physician, outcome information and health insurance status) to contact you or your family to raise money for St. Camillus/San Camillo. St. Camillus/San Camillo may also release this information to an organizationally-related foundation for the same purpose. You may choose to “opt-out” of receiving these fundraising communications by notifying the St. Camillus Foundation Director at 414‑259‑8335 that you do not wish to be contacted.

To Inform You About Information that May Be of Interest to You
St. Camillus/San Camillo may use or disclose your health information to tell you about or recommend possible options or alternatives for treatment, or to inform you of other information that may be of interest to you.

Release of Information to Family/Friends
Unless you specifically request in writing that St. Camillus/San Camillo not communicate with such person(s), St. Camillus/San Camillo may release your health information to a family member or friend who is involved in your treatment or who is helping pay for your care.

Business Associates
St. Camillus/San Camillo may disclose your health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for them to provide such functions or services. St. Camillus/San Camillo requires our business associates to agree in writing to protect the privacy of your health information and to use and disclose your health information only as specified in that written agreement.

Health Information Exchanges
St. Camillus/San Camillo may participate in an arrangement of health care organizations that have agreed to work with each other to facilitate access to health information that may be relevant to your care. For example, if you are admitted on an emergency basis to a hospital that participates in the exchange and you cannot provide important information about your condition, the arrangement will allow the hospital to access the health information St. Camillus/San Camillo maintains about you to treat you at the hospital.

THE FOLLOWING IS A SUMMARY OF THE OTHER CIRCUMSTANCES UNDER WHICH AND THE OTHER PURPOSES FOR WHICH ST. CAMILLUS/SAN CAMILLO MAY USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN CONSENT OR AUTHORIZATION:

When Legally Required
St. Camillus/San Camillo will disclose your health information to the extent that 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 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 St. Camillus/San Camillo reasonably believes a resident is the victim of abuse, neglect or domestic violence. St. Camillus/San Camillo will make this disclosure only when specifically required or authorized by law or when you authorize the disclosure.

To Conduct Health Oversight Activities
As permitted or required by State law, St. Camillus/San Camillo may disclose your health information to a health oversight agency for activities such as audits, civil, administrative or criminal investigations, inspections, and licensure or disciplinary action. If, however, you are the subject of a health oversight investigation, St. Camillus/San Camillo may disclose your health information only if it is 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. Under certain conditions, St. Camillus/San Camillo also may disclose your health information in response to a subpoena, discovery request or other lawful process.

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 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, St. Camillus/San Camillo 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 St. Camillus/San Camillo discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.

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 St. Camillus/San Camillo, 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 St. Camillus/San Camillo 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 use or disclose your health information other than with your written authorization. Your authorization (or the authorization of your representative) is specifically required before St. Camillus/San Camillo: (i) uses or discloses your psychotherapy notes; (ii) uses your health information to make a marketing communication to you for which it received financial remuneration from a third party, unless such communication is face-to-face or in other limited circumstances; or (iii) discloses your health information in any manner that constitutes the sale of such information under HIPAA. Also, some types of health information are particularly sensitive and the law, with limited exceptions, may require that St. Camillus/San Camillo obtain your authorization to use or disclose that information. Sensitive information may include information dealing with genetics, HIV/AIDS, mental health, developmental disabilities, and alcohol and substance abuse. If required by law, St. Camillus/San Camillo will ask that you (or your representative) sign an authorization before we use or disclose such information. If you (or your representative) authorize St. Camillus/San Camillo to use or disclose your health information, you (or your representative) may revoke that authorization in writing at any time, except to the extent that it has already been acted upon.

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 Receive Confidential Communications
You (or your representative) have the right to request that St. Camillus/San Camillo communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you (or your representative) may ask that St. Camillus/San Camillo only communicate with you pertaining to your health information privately with no other family members present. All requests for confidential communications must be made in writing using the appropriate St. Camillus/San Camillo form. This form can be requested by contacting the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing Residents: Administrator at 414‑258‑1814
Home Health Care Clients: Program Director at 414-258-2418

St. Camillus/San Camillo will accommodate reasonable requests. You (or your representative) will not be required to give a reason for your request.

Right to Request Restrictions
You (or your representative) have the right to request restrictions on certain uses and disclosures of your health information. For example, you (or your representative) have the right to request a limit on St. Camillus/San Camillo’s disclosure of your health information to someone who is involved in your care or the payment of your care.   All requests for restrictions must be made in writing using the appropriate St. Camillus/San Camillo form. This form can be requested by contacting the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing Residents: Administrator at 414‑258‑1814
Home Health Care Clients: Program Director at 414‑258‑2418

St. Camillus/San Camillo is not required to agree to your request; however, if we do agree, we are bound by that agreement except when otherwise required by law or in emergencies. Except as otherwise required by law, St. Camillus/San Camillo must agree to a restriction if: (1) the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and (2) the health information pertains solely to a health care item or service for which St. Camillus/San Camillo has been paid out of pocket, in full, by you or someone else on your behalf (not the health plan). If you self‑pay and request a restriction, it will apply only to those health records created on the date that you received the item or service for which you, or another person (other than the health plan) on your behalf, paid in full, and which document the item or service provided on such date.

Right to Inspect and Copy Your Health Information.
You (or your representative) have the right to inspect and copy your health information, including billing records. All requests to inspect and copy records must be made in writing using the appropriate St. Camillus/San Camillo form. This form can be requested by contacting the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing Residents: Administrator at 414‑258‑1814
Home Health Care Clients: Program Director at 414‑258‑2418

If you (or your representative) request a copy of your health information, St. Camillus/San Camillo will provide you (or your representative) copies of your health information in the format you requested unless we cannot practicably do so. St. Camillus/San Camillo may charge a reasonable fee for copying and assembling costs associated with your request. St. Camillus/San Camillo may deny your request to inspect and/or copy your health information in certain limited circumstances. If St. Camillus/San Camillo denies your request, you (or your representative) may request that we provide you with a review of our denial. Reviews will be conducted by a licensed health care professional who we have designated as a reviewing official, and who did not participate in the original decision to deny the request.

Right to Amend Your Health Information.
If you (or your representative) believe that your health information is incorrect, you (or your representative) have the right to request that St. Camillus/San Camillo amend your records. That request may be made as long as St. Camillus/San Camillo still maintains your records and it must include a reason for the request.

All requests for amendment must be made in writing using the appropriate St. Camillus/San Camillo form. This form can be requested by contacting the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing 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 may also be denied if the requested amendment pertains to health information that was not created by St. Camillus/San Camillo, if the records you are requesting to amend are not part of St. Camillus/San Camillo’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 St. Camillus/San Camillo, 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. All requests for accounting must be made in writing using the appropriate St. Camillus/San Camillo form. This form can be requested by contacting the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing 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, which may not be in excess of six 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 Joint Notice
You (or your representative) have a right to a separate paper copy of this Joint Notice at any time even if you (or your representative) have received this Joint Notice previously. You (or your representative) may also obtain a copy of the current version of our Joint Notice at our website, www.stcam.com. To obtain a separate paper copy, please contact the appropriate individual below:

Independent Living Residents: Program Director at 414‑259‑6300
Assisted Living Residents: Program Director at 414‑258‑1814
Skilled Nursing Residents: Administrator at 414‑258‑1814
Home Health Care Clients: Program Director at 414‑258‑2418

Right to a Breach Notification. You (or your representative) have a right to be notified of any breach of your unsecured health information. Notification of a breach may be delayed or not provided if so required by a law enforcement official. If you are deceased and there is a breach of your health information, the notice will be provided to your next of kin or personal representative if St. Camillus/San Camillo knows the identity and address of such individual.

CONTACT PERSON
St. Camillus/San Camillo has designated the St. Camillus Health System, Inc. 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 Health System, Inc.
10101 W. Wisconsin Avenue
Wauwatosa, WI 53226
414‑259‑3775

CONCERNS AND COMPLAINTS
St. Camillus/San Camillo 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 expressing your concerns or filing a complaint. You (or your representative) have the right to express complaints to St. Camillus/San Camillo or to the Secretary of Health and Human Services if you (or your representative) believe that your privacy rights have been violated. Any complaints to St. Camillus/San Camillo may be made by calling the St. Camillus Privacy Officer at 414‑259‑3775 or by writing to 10101 W. Wisconsin Avenue, Wauwatosa, WI 53226.

EFFECTIVE DATE
This Joint Notice is effective September 15, 2013.