The purpose of this form is to provide you with written information regarding BLOOM HEALTH’s compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. Additional information is available from the U.S. Department of Health and Human Services. Visit www.hhs.gov for more info. In order to deliver high quality and professional care while protecting your PHI, BLOOM HEALTH has adopted the following policies:

1) Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, or health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2) BLOOM HEALTH agrees to abide by the HIPAA Security Rule in regard to national security standards to protect health data created, received, maintained or transmitted electronically, also known as electronic protected health information (ePHI).

3) It is the policy of BLOOM HEALTH to remind patients of their appointments. We may do so by telephone, email, text, or by any means convenient for the practice and/or as requested by you.

4) BLOOM HEALTH uses a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

5) You understand and agree to inspections of BLOOM HEALTH by government agencies or insurance payers in normal performance of their duties, and their review of documents which may include PHI.

6) You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or your BLOOM HEALTH provider.

7) BLOOM HEALTH agrees to provide patients access to their records in accordance with state and federal laws.

8) We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.

9) You have the right to request restrictions or changes in certain policies used within the office concerning your PHI. However, BLOOM HEALTH is not obligated to alter internal policies to conform to your request.