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.
Your health information is personal, and we are committed to protecting it.
For purposes of this Notice, “Blossom Healthcare, Inc” and the pronouns “we,” “us” and “our” refer to Blossom Healthcare, Inc., its subsidiaries and affiliates under common ownership, and its contracted or employed health care providers.
Blossom Healthcare, Inc uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, to evaluate the quality of care that you receive, and for other purposes permitted by HIPAA and applicable law. Blossom Healthcare, Inc is required by law to maintain the privacy of your health information and provide you a notice of our legal duties and privacy practices with respect to that information, and provide you with notice of a breach of your unsecured protected health information.
This Notice applies to all records about your care that are created, and/or maintained by Blossom Healthcare, Inc. Your health information is contained in a medical record that is the physical property of Blossom Healthcare, Inc. Blossom Healthcare, Inc is required to abide by the terms of this Notice.
Blossom Healthcare, Inc reserves the right to change its privacy practices, as reflected in this Notice, to revise this Notice, and to make the new provisions effective for all protected health information it maintains. Revised Notices will be available on our website or upon your request.
How Blossom Healthcare, Inc May Use or Disclose Your Health Information:
We may use or disclose your health information, in certain situations, without your consent or authorization. Below we describe examples of how we may use or disclose your health information as permitted under or required by federal law, including instances where we will obtain your authorization. Such uses or disclosures may be in oral, paper, or electronic format.
For Treatment. Blossom Healthcare, Inc may use and disclose your health information to provide you with mental health treatment or services or to assist in the coordination, continuation, or management of your care and any related services. This includes the coordination or management of your health care with a third party. For example, a health care provider, such as a licensed professional counselor, or other person providing health services to you, will record information in your record that is related to your treatment and may share that information with other providers. This information is necessary for other health care providers to determine what treatment you should receive.
For Payment. Blossom Healthcare, Inc may use and disclose your health information to others for purposes of obtaining payment for treatment and services that you receive. For example, a bill may be sent to you or to a third-party payer, such as an insurance company or health plan, for services provided to you. The information on the bill may contain information that identifies you, your diagnosis, and your treatment.
For Health Care Operations. Blossom Healthcare, Inc may use and disclose health information about you for operational purposes. For example, your health information may be used by Blossom Healthcare, Inc or disclosed to others in order to:
- Evaluate the performance of our staff and/or contracted providers;
- Assess the quality of care and outcomes in your case and similar cases through auditors and/or evaluators;
- Learn how to improve our services; and
- Train other health care professional students or interns.
Communications. Blossom Healthcare, Inc may use and disclose your information to provide appointment reminders, leave a message on your answering machine, or leave a message with an individual who answers the phone at your residence. We may, from time to time, contact you to provide information about treatment alternatives and services that may be of interest to you. We may also provide you with informational materials including information about Blossom Healthcare, Inc. Material may come from a third party.
Required or Permitted by Law. Blossom Healthcare, Inc may use and disclose information about you as required or permitted by law. If a use or disclosure is required by law, the use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. If required by law, you will be notified of any such uses or disclosures. For example, Blossom Healthcare, Inc may use and/or disclose information for the following purposes:
- For judicial and administrative proceedings pursuant to legal authority or court order;
- To assist law enforcement officials in their law enforcement duties;
- In the instance of a breach involving your unsecured health information, notify you, law enforcement and regulatory authorities, as necessary, of the situation, and others as appropriate to help resolve the situation; or
- To health oversight agencies responsible for monitoring the health care system and government programs.
Public Health. Your health information may be used or disclosed for public health activities such as (1) assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability; (2) reporting child abuse or neglect to a public health authority or other governmental authority that is authorized by law to receive such reports; and (3) notifying a person who may be at risk of contracting or spreading the disease if such disclosure is authorized by law.
Individuals involved in your care. We may provide information about you to a family member, friend, or other person involved in your health care or in payment for your health care. If you are deceased, we may disclose medical information about you to a friend or family member who was involved in your medical care prior to your death, limited to information relevant to that person’s involvement, unless doing so would be inconsistent with your written wishes you previously provided to us. If we disclose information to a family member, relative, or close personal friend, we will disclose only information that we believe is relevant to that person’s involvement with your health care or payment related to your health care.
Health and Safety. We may, consistent with applicable law and standards of ethical conduct, use or disclose health information about you if we believe that the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of a person or the public; provided that, if a disclosure is made, it must be to a person(s) reasonably able to prevent or lessen the threat and is permissible by law. We may also use or disclose your health information if we believe that the use or disclosure is necessary for law enforcement authorities to identify or apprehend an individual who: (i) admits to participation in a violent crime that we reasonably believe caused serious physical harm to the victim, or (ii) appears to have escaped from a correctional institution or lawful custody.
Notification and Disaster Relief. We may use or disclose your health information to notify or assist in notifying your family, a personal representative, or another person responsible for your care, of your location, condition, or death. We may disclose your health information to disaster relief authorities so that your family can be notified of your location and condition.
Decedents. Health Information may be disclosed to funeral directors, medical examiners, or coroners to enable them to carry out their lawful duties. Once you have been dead for 50 years (or such other period as may be specified by law), we may use and disclose your health information without regard to the restrictions set forth in this Notice.
Government Functions. We may disclose your health information for specialized government functions, such as military and veteran’s activities, national security and intelligence activities, and protection of public officials.
Workers’ Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.
Business Associates. We may contract with one or more third parties, our business associates, in the course of our business operations. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. We require that our business associates sign a business associate agreement and agree to safeguard the privacy and security of your health information.
Authorizations for Other Uses and Disclosures:
While we may use or disclose your health information without your written authorization as explained above, there are other instances where we will obtain your written authorization. Except as otherwise provided in this Notice, we will not use or disclose your health information without your prior written authorization. You may revoke an authorization at any time, except to the extent Blossom Healthcare, Inc has already relied on the authorization and taken action.
Examples of uses and disclosures that require your authorization are:
Psychotherapy Notes. If Psychotherapy Notes are created for your treatment, we must obtain your prior written authorization before using or disclosing them, except (1) if the creator of those notes needs to use or disclose them for treatment, (2) for use or disclosure in our own supervised training programs in mental health, or (3) for use or disclosure in connection with our defense of a proceeding brought by you. “Psychotherapy Notes” means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. “Psychotherapy Notes” excludes medication prescription and monitoring, counseling session starts and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Note that if in the sole discretion of your health care provider, providing you with copies of your Psychotherapy Notes could be harmful or detrimental, we have the right to deny your request for such records.
Marketing. If we use or disclose your health information for marketing purposes, we must first obtain your written authorization to do so, except if the communication is face-to-face by us to you or is a promotional gift of nominal value.
No Sale of Your Health Information. We will never sell your health information to a third party. Period. Our Promise.
Uses and Disclosures of Your Highly Confidential Information. Some federal and/or state laws require special privacy protections for certain highly confidential health information, relating to (1) psychotherapy services; (2) mental health and developmental disabilities services; (3) substance use disorder diagnosis, treatment, and referral; (4) HIV/AIDS testing, diagnosis or treatment; (5) venereal disease(s); (6) genetic testing; (7) child abuse and neglect; (8) domestic abuse of an adult with a disability; and/or (9) sexual assault. Unless a use or disclosure is permitted or required by law, we will obtain your written consent or authorization prior to using or disclosing your highly confidential health information to third parties.
Your Health Information Rights:
You have the following rights regarding your health information. To exercise any of the rights below, please contact Blossom Healthcare, Inc at email@example.com to obtain the proper forms.
You have the right to:
Request a restriction on the uses and disclosures of your information for treatment, payment, and health care operations, or request a limit on the health information we disclose about you to someone involved in your care or the payment for your care, like a family member or a friend:
- If you have paid for a service or health care item out-of-pocket in full, and you ask us not to share that information with your health insurer for purposes of payment or our operations (not treatment), we will agree with your request unless a law requires us to share information. For all other requests, we will consider your request.
- Your request must be in writing, and we will notify you of our decision in writing.
- If we do agree to your request, we will comply with your request unless the information is needed to provide you with emergency treatment.
- Except for restrictions that we must comply with relating to health plans, we may terminate our agreement to a restriction at any time by notifying you in writing, but our termination will only apply to information created or received after we sent you the notice of termination, unless you agree to make the termination retroactive.
Obtain a paper copy of this Notice upon request. You may obtain a paper copy of this Notice by contacting firstname.lastname@example.org. The Notice is also available on our website, www.bhcpediatric.com.
Inspect and obtain a copy of your health and billing records. All requests to inspect or copy your health information or to access directly your records must be in writing. Blossom Healthcare, Inc can provide a form for you to use upon request. In certain circumstances, we may deny your request for inspection or copying, but if we do, we will notify you in writing of the reason(s) for the denial and explain your right to have the denial reviewed. If the information is maintained electronically and if you request an electronic copy, we will provide you with an electronic copy in the form and format requested by you, if it is readily producible in that form and format (if it is not, then we will agree with you on a readable electronic form and format). You can direct us to transmit the copy directly to another person if you submit a signed written request that identifies the person to whom you want the copy sent and where to send it. If you request copies, we may charge a reasonable cost-based fee for the labor involved in copying the information, the supplies for creating the paper copy, or the cost of the portable media, postage, and providing a summary of your records, if you request a summary.
Request an amendment to your health information. You may request that your health record be amended if you believe that the health information, we have about you is incomplete or incorrect. Requests to amend your health information must be in writing. We may deny your request and if we do, we will notify you in writing of the reason for the denial and your right to submit a statement disagreeing with the denial.
Request confidential communications. You have the right to ask Blossom Healthcare, Inc to communicate health information to you using alternative means or at alternative locations. Such requests must be in writing. We will accommodate reasonable requests and will notify you if we are unable to agree to your request. We may condition our agreement on information as to how payment will be handled and the specification of an alternate address or another method of contact.
Receive an accounting of disclosures of your health information. You have the right to obtain a list of instances in which Blossom Healthcare, Inc has disclosed your health information except in certain instances. These instances include but are not limited to: disclosures for treatment, payment, and health care operations; disclosures made to you; disclosures incident to a use or disclosure permitted or required by the Federal HIPAA Privacy Rule; disclosures authorized by you; and disclosures occurring more than six years prior to the date of your request. Your request must be in writing. The first disclosure list in a year is free; if you request additional lists in any year, we may charge you a fee.
You may complain to Blossom Healthcare, Inc. and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.
If you have any questions or complaints about this notice or our privacy practices, please contact:
Blossom Healthcare, Inc.