Christopher A. Bloom, M.D.

Diplomate of the American Board of Internal Medicine

Private Policy

WHEN IS THE NOTICE EFFECTIVE?

This notice became effective on January 1, 2007. C.A. Bloom, M.D. PLLC reserves the right to make the revised notice apply for all health information that we already have about you, as well as any information we receive in the future. We are required to abide by the terms of this notice currently in effect. The current notice is available on our Web site at: www.drchristopherbloom.com

TO WHOM DOES THIS NOTICE APPLY? This notice applies to:

  • C.A. Bloom, M.D. PLLC workforce

  • Any member of a volunteer group who may help you while you are seeking healthcare at C.A. Bloom, M.D. PLLC

    Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU CAN GET ACCESS TO THIS INFORMATION, YOUR RIGHTS CONCERNING YOUR HEALTH INFORMATION AND OUR RESPONSIBILITIES TO PROTECT YOUR HEALTH INFORMATION. PLEASE READ IT CAREFULLY.

    Dear Patient,
    Federal law requires C.A. Bloom, M.D. PLLC to make this Notice of Privacy Practices (?Notice?) available to all persons and to make a good faith effort to obtain a signed document acknowledging patient?s receipt of this Notice.

    If you have any questions about this notice, please call me at 214.206.1445.

    Thank you,
    Privacy Officer
    C.A. Bloom, M.D. PLLC

    WHAT ARE OUR RESPONSIBILITIES TO YOU?
    Your health information is personal. We are required by law to protect the privacy of your health information, to provide you with this notice and will only release your health information and as allowed by law or with special written permission (authorization) from you. We use the minimal amount of health information needed to do our work. Only those who need your health information to provide services are allowed to use it. C.A. Bloom, M.D. PLLC protects your information whether verbal, on paper or electronic.

    HOW DO WE USE AND RELEASE YOUR HEALTH INFORMATION?
    C.A. Bloom, M.D. PLLC primarily maintains your health information in a secure electronic format. Your health information created or received by C.A. Bloom, M.D. PLLC will most often be used, shared or disclosed electronically. The following section explains some of the ways we are permitted to use and release health information without an authorization from you.

USE AND RELEASE OF YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION:
TREATMENT PURPOSES
While we are providing you with health care services, we may need to share your health information with other health care providers or other individuals who are involved in your treatment. Examples include doctors, hospitals, pharmacists, therapists, nurses and labs that are involved in your care. We may provide
proof of immunizations to schools for admission purposes with your permission and agreement.

PAYMENT PURPOSES
C.A. Bloom, M.D. PLLC may need to share a limited amount of your health information to obtain or provide payment for the health care services provided to you. Examples include:

  • Eligibility ? C.A. Bloom, M.D. PLLC may con-tact the company or government program that will be paying for your health care. This helps us determine if you are eligible for benefits, and if you are responsible for paying a co-payment or deductible.

  • Claims ? C.A. Bloom, M.D. PLLC and businesses we work with share health information for billing and payment purposes. For example, your doctor must submit a claim form to get paid, and the claim form must contain certain health information.

    HEALTH-CARE OPERATIONS PURPOSES
    C.A. Bloom, M.D. PLLC may need to share your health information in the course of conducting health care business activities that are related to providing health care to you. Examples include:
    Quality Improvement Activities ? C.A. Bloom, M.D. PLLC may use and release health information to improve the quality or the cost of care. This may include

    reviewing the treatment and services provided to you. This information may be shared with those who pay for your care, or with other agencies that review

    this data.
    Health Promotion and Disease Prevention ? We may use your health information to tell you about disease prevention and health care options. For instance, we

    may send you health care information on issues such as women?s health, cancer or asthma.
    Business Associates ? There are some services provided at C.A. Bloom, M.D. PLLC through contracts with Business Associates such as medical transcription

    services and record storage companies. Business Associates are required by Federal law to protect your health information.
    Audits ? C.A. Bloom, M.D. PLLC may use or release your health information to make sure that its business practices comply with the law and with C.A.

    Bloom, M.D. PLLC?s policies. Examples include audits involving quality of care, medical bills or patient confidentiality.
    Business Activities ? We may use or release your health information to perform internal business activities. Examples include business planning, computer-

    systems maintenance, legal services and customer services.
    OTHER PURPOSES
    Required By Law ? Sometimes we must report some of your health information to legal officials or authorities, such as law enforcement officials, court

    officials, governmental agencies or attorneys. Examples include reporting suspected abuse or neglect, reporting domestic violence or certain physical

    injuries, or responding to a court order, subpoena, warrant or lawsuit request.
    Public Health Activities ? We may be required to report your health information to authorities to help prevent or control disease, injury or disability. Examples

    include reporting certain diseases, injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.

    Health Oversight Agencies ? We may be required to release health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system, or for governmental benefit programs.

    Activities Related to Death ? Privacy protections do not apply to the medical record 50 years after death. We may be required to release health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death. We may release health information to family members and others who were involved in your care or payment for care after your death.

    Organ, Eye or Tissue Donation ? In the event of your death, we may release your health information to organizations involved with obtaining, storing or transplanting organs, eyes or tissue to determine your donor status.

    To Avoid a Serious Threat to Health or Safety ? As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and/or approaching threat to anyone?s health or safety.

    Military, National Security or Incarceration/Law Enforcement Custody ? We may be required to release your health information to the proper authorities so they may carry out their duties under the law. This may be the case if you are in the military or involved in national security or intelligence activities, or if you are in the custody of law-enforcement officials.

    Worker?s Compensation ? We may be required to release your health information to the appropriate persons to comply with the laws related to workers?

compensation or other similar programs that provide benefits for work-related injuries or illness.
Persons Involved in Your Care ? In certain situations, we may release health information about you to persons involved with your care, such as friends or family

members. We may also give information to someone who helps pay for your care. You have the right to approve such releases, unless you are unable to

function, or if there is an emergency.
Notification/Disaster Relief Purposes ? In certain situations, we may share your health information with the American Red Cross or another similar federal, state

or local disaster relief agency or authority, to help the agency locate persons affected by the disaster.
WHEN IS YOUR WRITTEN
AUTHORIZATION REQUIRED?
Except for the types of situations listed above, we must obtain your written permission known as an authorization for any other types of releases of your health information. An authorization is required for the sale of your health information or for marketing purposes. An authorization is required for most uses and disclosures of psychotherapy notes. If you provide us with an authorization to use or release health information about you, you may cancel (revoke) that authorization in writing at any time. Any authorization you sign may be cancelled (revoked) by following the instructions described on the authorization form. You may receive more information about this by contacting the Privacy Office.

Other uses and disclosures of your health information not described in this Notice may be made only with your written authorization, and you have the right to take back (revoke) your authorization.

WHAT ARE YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION?
C.A. Bloom, M.D. PLLC wants you to know your rights regarding your health information.

  • Right to Receive This Notice of Privacy Practices ? You have the right to receive a paper copy of this notice at any time. You may obtain a copy of the current notice in all clinical areas or by visiting our Website at www.drchristopherbloom.com

  • Right to Request Confidential Communications -- You have the right to ask that C.A. Bloom, M.D. PLLC communicate your health information to you in different ways or places. For example, you can ask that we only contact you by telephone at work, or that we only contact you by mail at home or at a post office box. We will do this whenever it is reasonably possible. You can find out how to make such a request by contacting the Privacy Office.

  • Right to Request Restrictions- You have the right to request restrictions or limitations on how your health information is used or released. We have the right to deny your request.

  • Paid In Full ? You may request that we not disclose your health information to your health plan if: you have paid for a health care item or service in full and paid for the item or service out of your own pocket. We must honor your request to restrict your health information from being disclosed to your health plan for purposes of payment or health care operations unless the disclosure is required by law. You may obtain information about how to ask for a restriction on the use or release of your health information to your health plan by contacting the Privacy Office.

  • Right to Access ?With a few exceptions, you have the right to review and receive a copy of your health information. Some of the exceptions include:

o Psychotherapy notes;

o Information gathered for court proceedings; and

o Any information your provider feels would cause you to commit serious harm to yourself or to others.
To receive a copy of your record, or to direct your health information to be sent to another person chosen by you, call 214-206-1445. This office will provide you with the necessary forms and assistance. You may request and receive an electronic copy of your electronic record. We may charge you a cost-based fee, which may include copying and/or mailing your health record to you. If you are denied access to your health record for any reason, C.A. Bloom, M.D. PLLC will tell you the reasons in writing. We will also give you information about how you can file an appeal if you are not satisfied with our decision.

? Right to Amend ? You have the right to ask that C.A. Bloom, M.D. PLLC?s information in your health record be changed if it is not correct or complete. You must provide the reason why you are asking for a change. You may request a change by sending a request in writing to the Privacy Office. This office will provide you with the necessary forms and assistance. We may deny your request if:

o We did not create the information;
o We do not keep the information;
o You are not allowed to see and copy the information; or o The information is already correct and complete.

? Right to a Record of Releases
(Accounting) ? You have the right to ask for a list of releases of your health information by sending a request in writing to the Privacy Office. Your request may not include dates earlier than the six years prior to the date of your request. If you request a record of releases more than once per year, C.A. Bloom, M.D. PLLC may charge a fee for providing the list. The list will contain only information that is required by law. This list will not include releases for treatment, payment, health care operations or releases that you have authorized.

? Right to be Notified of Disclosure of Unsecured Health Information- You have the right to be notified following a breach of your unsecured health information.

WHAT CAN YOU DO IF YOU HAVE A COMPLAINT ABOUT HOW YOUR HEALTH INFORMATION IS HANDLED?
If you believe that your privacy rights have been violated, you may file a complaint with C.A. Bloom, M.D. PLLC or with the U.S. Secretary of Health and Human Services. To receive help in filing a complaint with C.A. Bloom, M.D. PLLC, you may contact the Privacy Office at the address at the end of this notice. You will not be denied treatment, retaliated, or penalized in any way if you file a complaint.
PRIVACY OFFICER CONTACT
INFORMATION
Privacy Officer
C.A. Bloom, M.D. PLLC
1151 N. Buckner Blvd. Ste. 405
Dallas, Texas 75218
P: 214.206.1445