Notice of Privacy Practices – St Croix Therapy

NOTICE OF ST CROIX THERAPY, INC.’S 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 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 personnel. 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. SCT 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. USE 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. For Fundraising 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 be contacted. 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 to you. 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. Business Associates. 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 agreement. 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 care. 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 disease. – 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. For Worker’s Compensation. SCT may release your health information for worker’s compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION 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. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION YOU HAVE THE FOLLOWING RIGHTS REGARDING YOUR HEALTH INFORMATION THAT SCT MAINTAINS: Receive Confidential 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. Right 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. Right 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 individual. CONTACT PERSON 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 info@stcroixtherapy.org. You may also write to Executive Director at the following address: 742 Sterbenz Dr., Hudson, WI 54016 COMPLAINTS 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. EFFECTIVE DATE This Joint Notice is effective December 29, 2017.

NOTICE OF ST CROIX THERAPY, INC.’S 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 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 personnel. 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. SCT 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. USE 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. For Fundraising 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 be contacted. 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 to you. 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. Business Associates. 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 agreement. 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 care. 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 disease. – 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. For Worker’s Compensation. SCT may release your health information for worker’s compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION 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. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION YOU HAVE THE FOLLOWING RIGHTS REGARDING YOUR HEALTH INFORMATION THAT SCT MAINTAINS: Receive Confidential 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. Right 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. Right 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 individual. CONTACT PERSON 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 info@stcroixtherapy.org. You may also write to Executive Director at the following address: 742 Sterbenz Dr., Hudson, WI 54016 COMPLAINTS 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. EFFECTIVE DATE This Joint Notice is effective December 29, 2017.

742 Sterbenz Drive, Hudson, WI 54016