ssm health pharmacy- specialty services · ssm health specialty pharmacy offers an array of...
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T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
Dear Patient, The staff of SSM Health Specialty Pharmacy would like to welcome you and say thank you for using our pharmacy and services. SSM Health Specialty Pharmacy is committed to providing you the highest quality of care that is integrated as a collaborative team with your physician. This Welcome Packet includes material that will provide you information to get started with your care plan. Our team is here to help provide personalized consultations, ongoing follow ups, timely and accurate medications, refill reminders, and clinical evidence based recommendations for your care. We are here as a resource for you to optimize your treatment and care plan. Please fill out and return the Acknowledgment of Receipt and Consent Form and Patient Satisfaction Survey. If you have any questions, please contact the SSM Health Specialty Pharmacy. If you have any questions with any of the content of your welcome packet, please contact us. Sincerely, SSM Health Specialty Pharmacy Staff Contact us by
1. Phone : (608) 294-3784 OR 1 (800) 279-8200 [Option 1]
2. Email* : [email protected]
3. In Person: 1313 Fish Hatchery Rd. Madison, WI 53715
Our Specialty pharmacy team is available by any of the methods above from 8:30 AM to 5:30 PM Monday through Friday. After-Hours Services
If assistance is needed after our normal business hours, our phone answering service can connect you to the following options: a nurse on call to answer clinical questions or direct you to the appropriate care, or the SSM Health Specialty Pharmacy voicemail to leave a secure message that will be addressed the following business day. Please notify the call center if you have an urgent need regarding your specialty medication. If is urgent then the call center will direct you to an afterhours specialty pharmacist. Complaint Procedure
If your complaint is in regard to your personal health information or privacy, please fill out the Privacy Complaint Form. If your complaint is in regard to the general service you received, please fill out the Patient Concerns and Grievances Form. *This email is for general questions and comments and not intended for use of private medical information. SSM Health Specialty Pharmacy will not disclose protected health information through this email. Please contact SSM Health Specialty Pharmacy for methods of receiving protected health information electronically.
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
Welcome Packet Checklist and Patient FAQ
This Welcome Packet should contain the following
Welcome Packet Cover and Patient FAQ (this document)
Welcome Letter
Patient Rights and Responsibilities
Notice of Privacy Policy
Privacy Complaint Form
Patient Concerns and Grievances Form
Patient Satisfaction Survey
Medication and Sharps Disposal
Patient Instructions
Business Reply Envelope Frequently Asked Questions What is a specialty pharmacy? A specialty pharmacy provides individualized care and dispensing of specialty medications. Specialty medications are classified as treatments for chronic, serious, and/or complex conditions. They are often high priced and may require special handling and storage. SSM Health Specialty Pharmacy helps maximize the benefits by providing personalized care for our patients on these medications. Why should I use SSM Health Specialty Pharmacy? SSM Health Specialty pharmacy offers an array of services that are specific for your medication and disease state. SSM Health specialty pharmacy offers additional support such as proactive follow ups and monitoring with a pharmacist. If you have a SSM Health physician, these follow ups are documented and communicated directly with your physician. SSM Health Specialty Pharmacist is able to access your electronic medical records from SSM Health associated entities to provide you with the highest level of care by managing and interpreting your labs and notes from your physicians and clinical staff. SSM Health Specialty Pharmacy offers automatic refill reminders to help with adherence of your medication. We offer full in depth initial consultations with a pharmacist to help educate you about how to take your medication and what to expect. Also because our pharmacists are experts with specialty medications and the associated disease states, they can help provide recommendations to reduce and manage potential medication side effects or symptoms of your disease. What are your hours? SSM Health Clinic Specialty Pharmacy is open Monday through Friday from 8:30 AM to 5:30 PM. SSM Health clinic call representatives and nurse on call are available 24 hours 7 days a week. You can contact them by calling SSM Health Clinic Specialty Pharmacy after business hours at (608) 294-3784.
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
How do I pay for my prescriptions? SSM Health Specialty Pharmacy accepts payment methods of cash, personal check, Visa, MasterCard, and Discover. What if I cannot afford my medication or it is not covered by my insurance? SSM Health Specialty Pharmacy has patient financial representatives to assist with ensuring all avenues have been investigated to get you the medication recommended by your physician. Additionally our staff can help get you set up with manufacturer assistance programs if you qualify. Always call the SSM Health Specialty Pharmacy if you have any questions about financial assistance or your out of pocket cost. Phone number is (608) 294-3784. How long will it take to get my medication if I am having it delivered? For medications that require refrigeration they will come the next business day through a reputable courier. For non-urgent medication requests that are stable at room temperature they will be delivered through the United States Postal Service. Most will arrive within one to two business days. At any point if you need your medication sooner, SSM Health Specialty Pharmacy can expedite your delivery to accommodate this need. There is no additional charge for any standard or urgent shipping. Can I fill other medications at SSM Health Specialty Pharmacy? Yes, SSM Health Specialty Pharmacy is connected to a community pharmacy that can dispense maintenance or other non-specialty medications. These medications can be scheduled to be delivered along with your specialty medications. How can I receive evidence based information about my medication or condition? SSM Health Specialty Pharmacists are specialized and able to provide evidence based recommendation and guidelines upon request. SSM Health Specialty Pharmacy is able to send you written information to help educate and instruct how to properly take your medication or device. This information can be sent to you by mail, electronically, or picked up. You can view our website for additional clinical information. http://www.SSM Healthcare.com/patients/pharmacy/SSM Health-clinic-specialty-pharmacy-services/ My specialty medication requires injection. Where can I learn how to inject my medication? SSM Health Specialty Pharmacists can set up an appointment to teach you how to administer your medication either in person or over the phone. If you have an SSM Health Physician, SSM Health Specialty Pharmacy staff can assist in getting you set up for a nurse appointment to have an injection education session in an exam room with one of your SSM Health Physician’s nurses. If you are unable to schedule a time to meet with a SSM Health Specialty pharmacist or talk to one over the phone, SSM Health Specialty Pharmacy staff can help you get set up with a nurse educator from the manufacturer of your medication if they provide that service. How long will the initial pharmacist consult take? SSM Health Specialty Pharmacists provide individualized care to meet your specific needs. The length of the consult depends on the number of questions and your previous experience with your medication or similar medications. On average you should schedule 15 to 30 minutes for the initial consult. How do I contact a pharmacist for health or medication related question? SSM Health Specialty Pharmacy has a patient management program that consists of patient outreach services. To speak with a pharmacist regarding clinical questions or follow up to a message left from the patient outreach program, you can call the main pharmacy phone number, or ask in person at the Fish Hatchery Pharmacy.
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Patient Information and Instructions
Automatic Refill Reminder The automatic refill reminder system will notify you when you are due for a refill. This occurs 5 to 10 days before your medication is needed, but can be edited to your preference. If your preference is set as delivery, an automatic phone call will go out to remind you to set up delivery. If your prefer to have your medication picked up at any of our 7 SSM Health Pharmacy locations, we will send you an automatic phone call prior to needing the medication. We ask that you call us back to confirm you want to pick it up at one of our pharmacy locations. We will get it to the pharmacy by the next business day at 4 PM. If your medication is not picked up within 14 days, you will receive a phone call notification that the order will be cancelled. You are allowed to opt out of the automatic refill reminder at any time by contacting the specialty pharmacy. Order medication refills You can order medication refills by the following methods:
1. Call or leave a detailed voice message with the SSM Health Specialty Pharmacy at (608) 294-3784 or toll free at 1 (800) 279-8200 [Option 1]
2. Talk to SSM Health Specialty Pharmacy staff in person at the SSM Health Fish Hatchery Rd. Clinic 3. If enrolled, reply to a MyChart message initiated by a pharmacy staff member. 4. Go online to https://www.ssmhealth.com/pharmacy
Next day shipments can be made on Monday through Thursday for delivery Tuesday through Friday. All orders must be made by 2:00 PM CST in order to guarantee next day delivery. If there is not enough information supplied for dispensing the medication, a SSM Health Specialty Pharmacy staff member will call to confirm the delivery date and location where you would like to receive the medication. Recalled medications If a manufacturer issues a recall on a medication you have received, SSM Health Specialty Pharmacy staff will notify you of the recall and provide instructions recommended by the manufacturer. SSM Health Specialty Pharmacy staff will work to promptly replace or find alternative medication to minimize the number of missed doses. Discontinued and Out of Stock medications If a medication you are taking is discontinued by the manufacturer or is currently unavailable, SSM Health Specialty Pharmacy staff will notify you upon your next refill. A clinical staff member will work with you and your doctor to find an alternative. For out of stock medications with generic alternatives see: Medication Substitutions.
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
Medication Substitutions SSM Health Specialty Pharmacy has the right to dispense a generic substitution of the medication prescribed as determined by the law. You will be notified if you are dispensed a medication from a different generic manufacturer. Collaborative Practice SSM Health Specialty Pharmacists work closely with Dean Medical Group Physicians in providing a high quality of care for our patients. We have collaborated with physicians to create agreements to help guide clinical decisions and efficiently start treatment. SSM Health Specialty Pharmacy has the right to switch and/or order medications as allowed by a written collaborative practice agreement. SSM Health Specialty Pharmacy will notify you of any new orders or changes from the original order. Transferring prescriptions Some prescriptions may not be able to be filled by SSM Health Specialty Pharmacy due to insurance requirements or manufacturer restrictions. If SSM Health Specialty Pharmacy cannot fill the prescription we will determine where it can be filled, transfer it to that pharmacy, and notify you of the prescription transfer along with the new pharmacy’s contact information. If there are multiple pharmacies that are allowed to fill your prescription, we will contact you and send it the pharmacy of your preference. Emergency Refill If a medication refill is needed the same day, call the SSM Health Specialty Pharmacy at (608) 294-3784 or call our toll free number at 1 (800) 279-8200 [Option 1]. If the medication is in stock, the SSM Health Specialty Pharmacy staff will prepare the medication for immediate pick up at the SSM Health Fish Hatchery Pharmacy or for same day courier delivery location. Exceptions can also be requested for Saturday deliveries. Any charge for same day or Saturday delivery by the courier will be charged to you at the pharmacy’s discretion. You must agree to charges before same day or Saturday delivery can be made. In the instance that the medication request is not during business hours, or cannot be received the same day, you should call Dean On Call at 1-800-576-8773 to speak with a nurse to determine if immediate medical care is required. Additional Information on your medication or disease state If you wish to receive more information regarding your medication please contact the SSM Health Specialty Pharmacy or go online to https://www.ssmhealth.com/pharmacy
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PRIVACY COMPLAINT FORM
Both federal and state law provide for confidentiality of your protected health information, including information maintained in your medical record. It is SSM Health Care System’s policy to maintain the confidentiality of all such information and to not use or disclose it without the consent or authorization of the patient or as specifically allowed by law. To that end, we treat our patients’ concerns about our privacy practices very seriously. You may use this form to let us know of any privacy concerns you may have concerning our use or disclosure of your protected health information. Once the SSM Health Care System Privacy Officer receives this complaint, he or she will review it promptly. Once the review is completed, you will receive a written response from the Privacy Officer or his or her designee. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. For information on the procedures for filing such a complaint, please contact us at the address or phone number listed below. Filing this complaint does not affect your ability to receive treatment at any SSM Health Care location. Please complete this side only if you are filing a complaint related
to someone else’s protected health information.
Name: Patient Name Address: Patient Address: Date of Birth: Patient’s Date of Birth: Telephone: Patient’s Telephone: Please use the space below to explain your complaint: (continue on the back of this page if needed) Signature: Date: If applicable, please provide: Legal Representative’s Name: Relationship to Patient: Please send this form to: Privacy Officer, SSM Health Care, 1808 W. Beltline Hwy., Madison, WI 53713 Phone: (608) 250-1075
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Patient Rights and Responsibilities
As a patient participating in the SSM Health Specialty Pharmacy services, you are entitled to receive in writing your rights and responsibilities. It is the duty of SSM Health Specialty Pharmacy to ensure the care you receive is in compliance with the standing laws and regulations. The following are your rights and responsibilities as a patient of SSM Health Specialty Pharmacy.
YOU HAVE THE RIGHT TO:
1. Request and receive information in a timely manner about the services offered at SSM Health Specialty Pharmacy.
2. Be treated in a fair, courteous, and respectful way by all staff of SSM Health Specialty Pharmacy.
3. Receive products and services in a professional manner that is without discrimination related to your race, age, sex, religion, ethnic group, national origin, sexual preference, cultural or political beliefs, and/or any disability.
4. Receive information, treatment, and care from competent and qualified personnel. This includes the right to receive written instructions on self-care, safe administration of medication or devices, proper handling and storage of medication or devices, and necessary information for safe and efficacious use of the medication as intended by the prescribing physician.
5. Receive verbal or written information that is communicated at a level to which you understand.
6. Have your privacy and confidentiality maintained as described in the Notice for Privacy Practices.
7. Receive information about who gets your personal health information. This includes notification in the case of your health information being wrongfully disclosed.
8. Receive information and/or referrals in the case that SSM Health Specialty Pharmacy is unable to
provide you treatment or care. This includes any changes to the site or level of care as required by you or your insurance plan.
9. Decline participation, revoke consent, or disenroll in any or all services offered by SSM Health Specialty Pharmacy. This does not exempt you from the terms allowed and written in the benefits policy of your insurance plan.
10. Have care that is free from maltreatment as defined. Maltreatment means the intentional and
non-therapeutic infliction of physical pain of injury, or any persistent course of conduct intended to produce mental or emotional distress.
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
11. Express concerns, grievances, and complaints about the level of care you receive from SSM Health
Specialty Pharmacy without any reprisal. This includes the right to have the incident escalated if you are unsatisfied with the response or resolution.
12. Receive information regarding any charges or payments for services you received at SSM Health Specialty Pharmacy. This includes information on how to make payments of the charges incurred.
13. Receive medication and/or device products in a timely manner.
14. Receive medication and/or device products that have maintained their quality, purity, and integrity
as defined and recommended by the product’s manufacturer. This includes that you have received products that are not adulterated or misbranded.
15. Participate in the planning of your treatment and care plan. This includes the right to discuss alternative treatment options and the right to include family members and/or other patient representatives to be involved in your care.
16. Receive follow ups through our Pharmacist Patient Outreach Program. This includes receiving scheduled follow ups from a pharmacist either in person or over the phone. You will receive this service unless you elect to opt out of this program by contacting and notifying the SSM Health Specialty Pharmacy Staff by phone at(608) 294-3784, toll free at 1 (800) 279-8200 [Option 1] or by email at [email protected].
17. Receive information regarding the philosophy, characteristics, and details of the patient management program.
18. Identify the program’s staff members, including their job title, and to speak with a staff member’s supervisor or a health professional.
19. Receive information and instructions regarding medications or devices that are recalled or discontinued.
20. Have personal health information shared with the patient management program in accordance with state and federal law.
YOU HAVE THE RESPONSIBILTY TO:
1. Adhere to the plan of treatment as prescribed by your physician.
2. Communicate any barrier or concerns with following the instructions, using the device, or adhering to scheduled dosing intervals.
3. Participate in the development of plan for your treatment and care.
4. Be an active participant through your care plan with SSM Health Specialty pharmacy and any
transitions of care.
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5. Communicate to SSM Health Specialty Pharmacy staff any relevant information that relates or will change your treatment and care plan. This includes providing complete and truthful medical and personal information.
6. Notify SSM Health Specialty Pharmacy if you are going to be unavailable to receive your medication
as scheduled. It is your responsibility for any payments or damages to products that are incurred once the shipment or pick up of product has been confirmed with you or your representative and the dispensed product has left the pharmacy.
7. Provide payment in a timely manner for all copays, coinsurances, rental charges, and/or invoices
upon receipt from SSM Health Specialty Pharmacy. Payments are to be paid in full unless prior arrangements have been agreed by you or your representative and SSM Health Specialty Pharmacy.
8. Use the medication as directed by the physician and SSM Health Specialty Pharmacy. Modifying or
using the medication not as directed releases any liability by the pharmacy and the manufacturer. Please refer to the Damaged, Recalled, and Discontinued Medications section on the patient information sheet.
9. Provide SSM Health Specialty Pharmacy with your most current and active insurance coverage
information.
10. Notify SSM Health Specialty Pharmacy of any insurance or financial changes that could affect your treatment and care plan.
11. Notify SSM Health Specialty Pharmacy of any changes to your address, phone number, delivery
location, or delivery preferences.
12. Notify SSM Health Specialty Pharmacy of any errors with prescriptions or medications received from SSM Health Specialty Pharmacy.
13. Notify your provider that you are enrolled in the SSM Health Specialty Pharmacy Patient
Management Program.
14. Submit all forms and paperwork that are necessary to enroll in any pharmacy programs.
15. Treat SSM Health Specialty Pharmacy personnel with respect and dignity without discrimination as to race, age, sex, religion, ethnic group, sexual preference, cultural or political beliefs, and/or any disability or national origin.
If you have any questions or concerns regarding your rights and responsibilities please contact SSM
Health Specialty Pharmacy by phone at (608) 294-3784 or by email at
[email protected]. Please verify you have acknowledged and consented to your
Rights and Responsibilities by signing and returning the Statement of Acknowledgement of Receipt and
Enrollment into SSM Health Specialty Pharmacy Services.
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Patient Concerns and Grievances Form
Patients have a right to report any concerns, complaints, and grievances they experience with SSM Health Specialty Pharmacy. SSM Health Specialty Pharmacy values the feedback and every case will be taken seriously. Complaints and grievances will be addressed promptly upon receipt and the SSM Health Specialty Pharmacy supervisor will be notified of every case. Cases will be handled during the normal business hours of 8:30 AM to 5:30 PM Monday through Friday. To submit a concern, complaint, or grievance, you have the following options:
1. Complete this form and mail to: SSM Health Pharmacy - Fish Hatchery Road - Madison 1313 Fish Hatchery Rd. STE 300 Madison, WI 53715
2. Call us at (608) 294-3784 OR 1 (800) 279-8200 [Option 1] 3. Discuss in person at the SSM Health Specialty Pharmacy located at the address above.
Once the review is completed, you will receive a written or verbal response from a SSM Health Specialty Pharmacy staff member. If you do not feel the case has been resolved to your satisfaction you have the right to contact us and request that the case be re-reviewed and escalated. Filing this complaint does not affect your ability to receive treatment at any SSM Health location. Please complete this side only if you are filing a complaint related
to someone else. .
Name: Patient Name Address: Patient Address: Date of Birth: Patient’s Date of Birth: Telephone: Patient’s Telephone: Please use the space below to explain your complaint: (continue on the back of this page if needed) Signature: Date: If applicable, please provide: Legal Representative’s Name: ______
Relationship to Patient:
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
Medication and Sharps Disposal
Proper disposal of unused or expired medications is important for preventing accidental ingestion, drug diversion, or even environmental contamination. Instead of throwing them in the trash or flushing them down the toilet, medications can be safely disposed of at certain sites, including some pharmacies and police stations. If dropping medications off at a designated site is not an option, several steps are recommended for safe disposal, such as removing all labels and mixing medications with coffee grounds or cat litter to make them unattractive. Please see resources below for more information about medication disposal and medication disposal sites. Along with medication disposal, safe sharps disposal is also very important. According to the FDA, sharps refer to devices with sharp points or edges that can puncture or cut skin. Examples of sharps include needles, syringes, lancets, auto-injectors, and infusion sets. If sharps are not disposed properly, injury and transmission of infections to other people can occur. Many sharps disposal programs are simple to use and free of charge. They only require patients to properly package used needles in an approved container and drop them off at a participating pharmacy. All SSM Health Pharmacy locations will take properly packaged used sharps for safe disposal. Please see resources below for more information about sharps disposal and sharps disposal sites. Approved containers for needles or sharps include:
red plastic sharps containers (available at SSM Health Pharmacies upon request)
used plastic laundry detergent bottle labeled with a "Biohazard" or "Sharps" sticker
do NOT use plastic milk jugs or soda bottles
Resources
Medication Disposal
1. MedDrop- http://www.safercommunity.net/meddrop.php
List of MedDrop boxes in Dane County is near bottom of page
2. Dispose My Meds - http://www.disposemymeds.org/
Use pharmacy locator to find a pharmacy drop off location near you
Sharps Disposal
1. City of Madison- https://www.cityofmadison.com/streets/hazardous/householdsharps.cfm
2. WI DNR List of Sharps Collection Sites -
http://dnr.wi.gov/topic/waste/documents/faclists/sharpscollection.pdf 3. FDA - http://www.fda.gov/ and search “sharps” in search box
SSM Health Pharmacy- Specialty Services
1313 Fish Hatchery Road | Madison, Wisconsin 53715
Phone (608) 294 3784 | Fax (608) 283 7325
T (608) 294-3784 | F (608) 283-7325 | ssmhealth.com
Notice of Privacy Practices Effective Date: March 1, 2015
This Notice of Privacy Practices (“Notice”) serves as a notice for all SSM Health Care entities providing health care services (such SSM Health Care entities referred to collectively as “we” or “our”). This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this Notice carefully. If you have any questions about this Notice, please contact a registration representative at
the hospital, physician’s clinic or other SSM Health Care entity where you are receiving health care services.
Who Will Follow This Notice
This Notice applies to our workforce members, including employees, volunteers, students and trainees. This Notice also applies to other health care and service providers that provide care or services at our facilities, or for our patients, in that, as a condition to providing services at our facilities, such providers must agree to comply with our policies, including our policies relating to patient privacy. This Notice, however, only details our privacy policies and does not govern the independent practices or operations of health care and service providers, such as the privacy practices that your doctor, if not employed by us, may use in his or her private office.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the health care services you receive from us. We need this record to provide you with quality health care services and to comply with certain legal requirements. This Notice applies to all of the records of your care that we generate.
We are required by law to:
Make sure that medical information that identifies you is kept private;
Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
Follow the terms of the Notice that is currently in effect.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories:
For Treatment: We may use medical information about you to provide you with medical treatment or services. We may
disclose medical information about you to doctors, nurses, technicians, health care students, clergy, or others who are involved in your health care services. For example, your medical information may be shared with a physician to whom you have been referred in order to ensure that the physician has the necessary information to diagnose or treat you. We also may use your medical information to coordinate the different things you need, such as prescriptions, lab work and x-rays. If you are in one of our facilities, we also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave our facility.
For Payment: We may use and disclose medical information about you so that the treatment and services we provided
to you, or that was provided to you by another facility, provider, or physician, may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your treatment so they can pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose medical information about you to improve our services or
support our business activities. For example, we may use medical information to review our treatment and services, to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, health care students, and other personnel for review and learning purposes. We or our designee may send you a patient satisfaction survey via mail or to an email address that you provided to us. Specific individual information will not be included in the email without authentication of a specific patient identifier to access the survey.
Notice: SSM Health, Dean Health Systems and Dean Health Plan are part of an Organized Health Care
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Arrangement (OHCA). As part of the OHCA, we may from time to time share your information with other members of the OHCA in order to perform joint health care operations. For example, we may share your information in order to: improve population health management; conduct quality assessment and improvement activities; conduct or arrange for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general OHCA administrative activities.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an
appointment with us or to notify you that it’s time for you to schedule a medical service with us.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health related
benefits, services, or health education resources, such as screenings, seminars, classes, or other programs that may be of interest and beneficial to you.
Patient Assistance Programs: We may use and disclose your information to third parties for the purpose of
determining whether you qualify for a private or government patient assistance program that would reduce the amount you owe to SSM.
Fundraising Activities: We may use information about you to contact you in an effort to raise money for our operations.
For this purpose, we may use your name, address and phone number, the dates you received treatment or services and the department in which you received those services. If you do not want to be contacted for fundraising efforts, you will be given the opportunity to notify the appropriate Privacy Officer in writing.
Hospital Directory: If you are receiving health care services in one of our hospitals, unless you advise the registration
representative otherwise, we may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., good, fair, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may share information about you
to a care giver who may be a friend or family member. We may also give information to someone who helps pay for your care. If you are unable to object to such a disclosure, we may discuss your medical information with a family member, friend, or other person if, using professional judgment, we conclude that you do not object. Only the information that is relevant to your care or payment for your care will be disclosed.
Research: Under certain circumstances, we may use and disclose medical information about you for research purposes.
For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special internal approval process.
As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.
Special Situations: Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military: If you are a member of the armed forces, we may release medical information about you as required by military
command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation: Under Federal or State law, we may be required to provide copies of your medical
information in connection with a workers’ compensation claim to your employer, to you or your dependents, to certain state agencies or to others involved in your claim for compensation.
Public Health Risks (Health and Safety to you and/or others): We may disclose medical information about you for public
health activities. We may use and disclose medical information about you to agencies when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person or when we are legally
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required to do so. These activities generally include the following:
– To prevent or control disease, injury or disability;
– To report births and deaths;
– To report child abuse or neglect;
– To report reactions to medications or problems with products;
– To notify people of recalls of products they may be using;
– To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
– To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure when required or authorized by law.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized
by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in
response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.
Law Enforcement: To the extent permitted by law, we may release medical information if asked to do so by a law enforcement official. We may release medical information when we are legally permitted to do so:
– In response to a court order, subpoena, warrant, summons or similar process;
– To identify or locate a suspect, fugitive, material witness, or missing person;
– About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
– About a death we believe may be the result of criminal conduct;
– About criminal conduct at one of our facilities; and
– In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical
examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose medical information about you to authorized
federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Other uses of Medical Information: Most uses and disclosures of psychotherapy notes, uses and disclosures of
medical information for marketing purposes and certain disclosures that constitute a sale of your medical information will
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require your written permission. Additionally, other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:
– To inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical, laboratory and billing records, but may not include all psychotherapy notes.
– Request in writing to inspect and copy medical information that may be used to make decisions about you. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
– We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that another licensed health care professional chosen by us review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you have the right to
request in writing that we amend the information by providing the reason for the amendment. You have the right to request an amendment for as long as the information is kept by or for us.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
– Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
– Is not part of the medical information kept by or for us;
– Is not part of the information which you would be permitted to inspect and copy; or
– Is accurate and complete.
If we deny your request for an amendment, we will do so in writing and you have the right to file a statement of disagreement.
Right to an Accounting of Disclosures: You have the right to request in writing an "accounting of disclosures." This is
a list of the disclosures we made of medical information about you to others, excepting disclosures relating to treatment, payment and health care operations.
Your request must state a time period which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, or; electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Receive Notice of Breaches: You have the right to receive notifications of breaches of your unsecured
medical information.
Right to Request Restrictions, in General: You have the right to request in writing a restriction or limitation on the
medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery performed.
– We are not required to agree to your request. If we do agree, we will comply with your request unless the information is
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needed to provide you emergency treatment.
In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Restrictions to a Health Plan: You have the right to request in writing a restriction or limitation on the
medical information we disclose about you to a health plan for purposes of payment or health care operations if you, or someone on your behalf, has paid for the health care item or service out of pocket in full.
– If you, or someone on your behalf, have paid for the health care item or service out of pocket in full, we are required to agree to your request if the disclosure to the health plan relates to payment or health care operations.
In your request, you must tell us (1) the name of the health plan that is not to receive the disclosure; (2) what health care item or service you wish to restrict from disclosure; (3) the location in which the health care item or service was provided to you; and (4) the date the health care item or service was provided to you.
Right to Request Confidential Communications: You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
Please advise the registration representative how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time by requesting a copy from the registration representative.
Changes to this Notice:
We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facilities and this Notice will be available on the SSM Health Care website. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted as a patient, you have the right to request a copy of the current Notice in effect.
Questions about this Notice or Complaints:
If you have questions about this Notice or if you believe your privacy rights have been violated, you may contact the SSM Health Care Privacy/HIPAA Contact at (314) 994-7724. While we will make every effort to resolve any complaints, please know that you also have the right to file a written complaint with the Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.