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 Croix Therapy, Inc. (“SCT”) for purposes of
compliance with the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) has created the following privacy practice.
SCT does participate in an Organized
Health Care Arrangement (“OHCA”) with other covered entities. This will be considered a Joint Notice and is
jointly used by and jointly describes the practices of all participants
within the OHCA, including, without limitation:
– Any authorized health care professionals
assisting with any arrangement or treatment of care.
– All departments or units of SCT.
– Any member of a volunteer group or intern
we allow to help you while you are a client of, or being treated at, SCT.
– All employees, staff or other SCT
Each of the above-listed 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.
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. SCT
is required to abide by the terms of our Joint Notice and it may be amended
from time to time. SCT 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 SCT has created or maintained in the past, and for any
records that SCT creates or maintains in the future. SCT will post our current Joint Notice in a
prominent location in our facility, as well as on our website, www.stcroixtherapy.org.
AND DISCLOSURE OF HEALTH INFORMATION
THE FOLLOWING IS A
SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND THE PURPOSES FOR WHICH SCT MAY
USE OR DISCLOSE YOUR HEALTH INFORMATION:
To Provide Treatment.
SCT may use your health information to treat you and coordinate your
care within SCT. For example, SCT may
disclose your health information to individuals outside SCT involved in your
care, including family members, your primary care provider, suppliers of medical
equipment or other health care professionals.
To Obtain Payment.
SCT may use or disclose your health information to bill or collect
payment for services or items you receive from SCT. For example, SCT may be required by your
health insurer to provide information regarding your health care status so
that the insurer will reimburse you or SCT.
SCT 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. SCT may use your health information for our
own operations in order to facilitate the function of SCT and as necessary to
provide quality care to all SCT clients.
For example, SCT may use your health information to evaluate our staff
performance, combine your health information with that of other SCT clients
to evaluate how to more effectively serve all SCT clients, disclose your
health information to SCT 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. SCT 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, SCT 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.
Activities. In support of our charitable mission, SCT
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 SCT. SCT may also disclose 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 Executive
Directorthat you do not wish to
To Inform You About Health Information
That May Be of Interest to You. SCT may use or disclose your health
information to tell you about or recommend possible options or alternatives
for your care, or to inform you of other information that may be of interest
Release of Information to Family or
Friends. Unless you specifically request in writing
that SCT not communicate with such person(s), SCT 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.
SCT 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. SCT 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
Health Information Exchanges. SCT 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
THE FOLLOWING IS A
SUMMARY OF THE OTHER CIRCUMSTANCES UNDER WHICH AND THE OTHER PURPOSES FOR
WHICH SCT MAY USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN
CONSENT OR AUTHORIZATION:
When Legally Required.
SCT 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. SCT 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
– To an employer about an individual who is
a member of the workforce, as legally required.
To Report Abuse,
Neglect or Domestic Violence. SCT is allowed to notify government
authorities if SCT reasonably believes a resident is the victim of abuse,
neglect or domestic violence. SCT 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, SCT
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 agency, SCT 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, SCT 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, SCT 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, SCT
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. SCT 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.
SCT 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, SCT may disclose your health
information prior to and in reasonable anticipation of your death.
For Organ, Eye or
Tissue Donation. SCT 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.
SCT may, under very select circumstances, use your health information
for research. Before SCT 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. SCT may,
consistent with applicable law and ethical standards of conduct, disclose
your health information if SCT, 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 SCT 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.
Compensation. SCT may release your health information for
worker’s compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE
Other than as stated above, SCT 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 SCT: (1) uses or discloses your psychotherapy
notes; (2) uses your health information to make a marketing communication to
you for which it receives financial remuneration from a third party, unless
such communication is face-to-face or in other limited circumstances; or (3)
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 SCT obtain your authorization to
use or disclose that information.
Sensitive information may include information dealing with genetics,
mental health, developmental disabilities, and alcohol and substance abuse. If required by law, SCT will ask that you
(or your representative) sign an authorization before we use or disclose such
information. If you (or your
representative) authorize SCT 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.
RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
YOU HAVE THE FOLLOWING
RIGHTS REGARDING YOUR HEALTH INFORMATION THAT SCT MAINTAINS:
Communications. You (or your representative) have the right
to request that SCT communicate with you about your health and related issues
in a particular manner or at a certain location. For instance, you may ask that SCT only
communicate with you about your health privately with no other family members
or people present. All requests for
confidential communications must be made in writing. Such requests shall specify the requested
method of contact or the location where you wish to be contacted. SCT will accommodate reasonable
requests. You (or your representative)
do not need 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) may request a limit on SCT 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. SCT 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, SCT 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 SCT 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. If you (or your representative) request a
copy of your health information, SCT will provide you (or your
representative) a copy of your records in the format you request, unless we
cannot practicably do so. SCT may
charge a reasonable fee for any copying and assembling costs associated with
your request. SCT may deny your
request to inspect and/or copy your health information in certain limited
circumstances. If SCT 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
your health information is incorrect or incomplete, you (or your
representative) have the right to request that SCT amend your records. That request may be made as long as SCT
still maintains your records, and must include a reason for the
amendment. All requests for amendment
must be made in writing. SCT 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
your health information that was not created by SCT, if the records you are
requesting to amend are not part of SCT’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 SCT,
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 SCT for certain
purposes. All requests for an
accounting must be made in writing. SCT 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.
to a Paper Copy of this Joint Notice. You (or your
representative) have a right to receive a separate paper copy of this Joint
Notice at any time even if you (or your representative) have received this
Joint Notice previously. To obtain a
separate paper copy, call 715-386-2128 and ask to speak with the Executive
Director. A copy of our most current Joint Notice may
also be found on our website, www.stcroixtherapy.org.
to 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 SCT knows the identity and address of such
SCT has designated the Executive Director as its contact
person for all issues regarding client privacy and your rights under the
Federal privacy standards. If you have
any questions or concerns regarding this Joint Notice or your privacy rights,
call 715-386-2128 and ask to speak with the Executive Director or email SCT
at email@example.com. You may
also write to Executive Director at the following address:
742 Sterbenz Dr.,
Hudson, WI 54016
SCT 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 SCT or to the
Secretary of Health and Human Services if you (or your representative)
believe that your privacy rights have been violated. All complaints to SCT may be made by contact
the Executive Director.
Joint Notice is effective December 29, 2017.