Notice of Privacy Practices

Thank you for taking the time to learn about how we protect your privacy. 

Your privacy matters. We are committed to maintaining the confidentiality of your personal and health information while providing you with quality mental health care.

Need more details? We also offer a comprehensive version with extensive explanations, examples, and additional information. Download the Complete Notice of Privacy Practices (PDF) for the full version.

Mosaic Bloom Privacy Notice.docx

YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.

This notice describes how medical and psychological information about you may be used and disclosed and how you can access this information. Please review it carefully.

Your privacy is important to us. Federal and state laws require that we protect the privacy of your health information and provide you with this notice of our legal duties and privacy practices.

Questions? Contact us at 267-227-0122 or mbolden@mosaicbloomcounseling.com

QUICK REFERENCE

Your Rights:

  • Get a copy of your health record
  • Request corrections to your health record
  • Request confidential communications
  • Ask us to limit information we share
  • Get a list of those with whom we’ve shared information
  • Get a copy of this privacy notice
  • File a complaint if you feel your rights are violated

Our Uses of Your Information:

  • Treatment: Providing and coordinating your care
  • Payment: Billing you or your insurance company
  • Operations: Improving our services and meeting legal requirements

Your Choices:

  • You can tell us to share information with family, friends, or others involved in your care
  • You can tell us NOT to share certain information with your health insurance plan if you pay for the service in full out-of-pocket

HOW WE MAY USE AND SHARE YOUR HEALTH INFORMATION

Treatment

We can use and share your information to provide, coordinate, and manage your mental health care.

Example: We may consult with your psychiatrist or primary care physician about your treatment.

 

Payment

We can use and share your information to bill and receive payment from you or your health insurance plan.

Example: We submit claims to your insurance company that include your diagnosis and treatment information.

Insurance Disclosure: When you use insurance benefits, your diagnosis and treatment information become part of your insurance company’s records. The insurance company may share this with other entities such as the Medical Information Bureau (MIB). We are currently in-network with Aetna.

 

Health Care Operations

We can use and share your information to run our practice and improve the care we provide.

Example: We use your information to manage our practice, conduct quality improvement activities, and meet professional and legal requirements.

 

Technology We Use to Protect Your Information

We use Counsol, a HIPAA-compliant electronic health records system that includes encryption, secure access controls, and automatic data backups. We offer secure telehealth sessions via Doxy.me, a HIPAA-compliant video platform. Your secure client portal at mosaicbloom.secure-client-area.com is the safest way to share sensitive information.

 

For routine scheduling: Text (267-227-0122) or email (mbolden@mosaicbloomcounseling.com) are appropriate. For clinical matters, please use the secure portal or discuss during sessions.

WHEN WE MUST SHARE YOUR INFORMATION

We are required by law to share your information in these situations:

To Protect You or Others from Serious Harm

If we believe you are at risk of harming yourself or someone else, or if we believe you are a victim of abuse, neglect, or domestic violence.

To Report Child Abuse or Neglect

We must report suspected child abuse or neglect to appropriate authorities.

To Comply with the Law

When required by federal, state, or local law, in response to court orders or subpoenas, for health oversight activities (such as licensing board investigations), or for law enforcement purposes when legally required.

For Public Health and Safety

To prevent or control disease, injury, or disability, to report adverse reactions to medications, or to report product recalls.

For Worker’s Compensation

If you file a worker’s compensation claim, we must provide relevant records.

WHEN WE NEED YOUR WRITTEN PERMISSION

We will ask for your written authorization before using or sharing your information for purposes not covered in this notice, including:

  • Sharing information with family members, friends, employers, schools, or attorneys (except where required by law)
  • Most uses and disclosures of psychotherapy notes (personal process notes kept separate from your medical record)
  • Marketing purposes
  • Sale of your information
  • Most other uses not described in this notice

You can revoke your authorization at any time by notifying us in writing. The revocation will not affect information already shared based on your previous authorization.

YOUR RIGHTS

Get a Copy of Your Health and Claims Records

You can ask to see or get a copy of your health record and other information we have about you. We will provide a copy or summary of your information, usually within 30 days of your request. We may charge a reasonable, cost-based fee for copying and mailing.

Request Corrections

You can ask us to correct health information about you that you think is incorrect or incomplete. We may deny your request if the information is accurate and complete, but you can submit a statement of disagreement.

Request Confidential Communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will accommodate all reasonable requests.

Ask Us to Limit What We Share

You can ask us not to use or share certain information for treatment, payment, or operations. We are not required to agree to your request except: If you pay for a service out-of-pocket in full and ask us not to share information about that service with your health insurance plan, we will agree to your request.

Get a List of Those with Whom We’ve Shared Information

You can ask for an accounting of disclosures made in the last 6 years (excluding disclosures for treatment, payment, and operations). The first accounting in any 12-month period is free.

Get a Copy of This Privacy Notice

You can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically. We will provide you with a paper copy promptly.

Choose Someone to Act for You

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. For minor clients, parents/guardians generally have access to health information, with some exceptions as permitted by law.

YOUR CHOICES

For certain information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in these situations, talk to us:

  • With family, close friends, or others involved in payment for your care
  • In a disaster relief situation
  • If you are unable to tell us your preference (for example, in an emergency), we may share information if we believe it is in your best interest.

MULTI-STATE PRACTICE

We are licensed to provide services in Pennsylvania, Delaware, New Jersey, and Idaho. Your information is protected under federal HIPAA laws as well as applicable state privacy laws. When state law provides greater privacy protections than federal law, we follow the more protective law.

For telehealth services, you must be physically located in one of our licensed states at the time of the session.

PSYCHOTHERAPY NOTES

Psychotherapy notes (also called process notes) are the therapist’s personal observations kept separate from your medical record. These notes have extra privacy protections and cannot be released without your specific written authorization, except in very limited circumstances (such as for our own training or legal defense).

Your medical record (which includes diagnosis, treatment plans, session notes, and progress) is separate from psychotherapy notes and may be used for treatment, payment, and operations as described in this notice.

BREACH NOTIFICATION

If there is a breach (unauthorized access or disclosure) of your unsecured health information, we will notify you within 60 days. The notification will explain what happened, what information was involved, what we’re doing about it, and steps you can take to protect yourself.

We take security seriously and use encryption, secure systems, staff training, and regular security assessments to protect your information.

OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you give us written permission, you may change your mind at any time by letting us know in writing.
  • We will use and disclose only the minimum necessary information to accomplish the intended purpose.

CHANGES TO THIS NOTICE

We can change the terms of this notice at any time. Changes will apply to all information we have about you. The new notice will be available in our office and on this website.

SOCIAL MEDIA AND BOUNDARIES

To protect your privacy and maintain professional boundaries:

  • We do not accept friend requests or connections on personal social media.
  • We do not monitor social media for client communications.
  • If we see you in public, we will not acknowledge our relationship unless you initiate contact.
  • Online messages should be sent through the secure portal, not social media platforms.

QUESTIONS AND COMPLAINTS

Questions?

Marquita Bolden, LCSW

Phone: 267-227-0122

Email: mbolden@mosaicbloomcounseling.com

Website: www.mosaicbloomcounseling.com

Secure Portal: https://mosaicbloom.secure-client-area.com

 

Complaints

If you believe your privacy rights have been violated, you can file a complaint with:

Mosaic Bloom Counseling

Marquita Bolden, LCSW

8302 Old York Road, Suite B1

Elkins Park, PA 19027

 

Office for Civil Rights

U.S. Department of Health and Human Services

801 Market Street, Suite 9300

Philadelphia, PA 19107-3134

Phone: 1-800-368-1019

Fax: 202-619-3818

TDD: 1-800-537-7697

Email: ocrmail@hhs.gov

Website: www.hhs.gov/ocr/privacy/hipaa/complaints

 

You will not be penalized or retaliated against for filing a complaint.

ADDITIONAL INFORMATION

For comprehensive details on all aspects of our privacy practices, including detailed explanations of your rights, insurance disclosures, multi-state considerations, minor client protections, and more, download the complete Notice of Privacy Practices.

Mosaic Bloom Privacy Notice.docx