Partners In Ministry
Serving Those Who Serve
IMPORTANT NOTICES
IMPORTANT HEALTH COVERAGE TAX DOCUMENTS
THIS NOTICE is required under congressional act H.R. 3797 – “Paperwork Burden Reduction Act”: You may receive a copy of your form 1095-B “Health Coverage” or form 1095-C “Employer-Provided Health Insurance Offer and Coverage” by sending your request to:
By Email: Finance@stambrosefinancial.com
By Mail:
Your Employer’s Name
C/O St Ambrose Financial Services, Inc. Accounting Dept
P.O. Box 4004
La Crosse, WI 54602-4004
By Phone: 608-791-2669 ext. 9894
Contact Name: Dan Fitzpatrick, Director of Operations – St. Ambrose Financial Services, Inc.
Please include the following information in your request:
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Your Employer’s Name and City
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Your Name: First Name MI Last Name
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What you are requesting: Specify Email or Paper copy of your 1095 Form
IMPORTANT NOTICE OF PRIVACY PRACTICES
THIS NOTICE of the Privacy Rule includes who is covered, what information is protected, and how protected health information can be used and disclosed. Because it is an overview of the Privacy Rule, it does not address every detail of each provision.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 establishes federal standards protecting sensitive health information from disclosure without patient's consent. The US Department of Health and Human Services issued the HIPAA Privacy Rule to implement HIPAA requirements.
Privacy Official: Dan Fitzpatrick, Director of Operations – St. Ambrose Financial Services, Inc.
Email: dfitzpatrick@stambrosefinancial.com
Phone: 608-519-9893