Notice of Privacy Practices

Bloom Therapy & Well-being, PLLC

NOTICE OF PRIVACY PRACTICES

This notice describes how health information may be used and disclosed and how you can access this information. Please review this notice carefully.

I understand that health information about you (the client) and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this therapy practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice.

  • Follow the terms of the notice that is currently in effect.

  • I reserve the right to change the terms of the Notice of Privacy Practices at any time. If I change the terms of the Notice of Privacy Practices, the changes will go into effect immediately and will apply to all PHI that I maintain at that time.  I will provide you with an updated copy of the new Notice of Privacy Practices through the client portal messaging and will post the updated version on my website.

HOW I MAY USE AND DISCLOSE PHI

The following categories describe different ways that I may use and disclose health information. Not every use or disclosure in a category will be listed. 

For Treatment: I may use and disclose your health information internally in the course of your treatment.  If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

For Payment: I may use and disclose your health information to obtain payment for services provided to you. 

For Health Care Operations: I may use and disclose your health information to carry out our internal operations.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations in the law, I can use and disclose PHI without your authorization, including, for the following reasons:

  • When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

  • If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, or any other person responsible for the child's welfare.

  • If I know or have reasonable cause to suspect that an elderly person or a person with a disability has been abused, neglected, or exploited.

  • If I believe that there is a clear and immediate probability of physical harm to the client, to other individuals, or to society. In such case, I may be required to disclose information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the client.

  • If a government agency is requesting the information for health oversight activities, within its appropriate legal authority.

  • If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

  • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. 

  • For law enforcement purposes, including reporting crimes occurring on my premises.

  • To coroners or medical examiners, when such individuals are performing duties authorized by law.

  • For workers’ compensation purposes where I am providing necessary treatment related to that claim. In such case, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the client's employer, the insurance carrier or an authorized qualified rehabilitation provider.

RIGHTS WITH RESPECT TO PHI

  • The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request.

  • The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  • The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

  • The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes” or “progress notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 60 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

  • The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

  • The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

  • The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email or portal message. And, even if you have agreed to receive this Notice via email or portal message, you also have the right to request a paper copy of it.

COMPLAINTS 

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me by mail at Jennifer Freifeld, LCSW, Bloom Therapy & Well-being, PLLC,  220 Grande Heights Dr., #1031  Cary, NC 27513. 

You may also contact the State of North Carolina Department of Health or the Secretary of the U.S. Department of Health and Human Services.


This notice went into effect November 1, 2022.