Privacy Policy

Privacy Policy

Notice of Patient Privacy Practices and Rights

Name of Practice: Bloom Physical Therapy and Wellness

This notice describes how medical information about you may be disclosed and used, and how you can get access to this information.  Please read carefully.

Your basic rights and our basic responsibilities under HIPAA.  Patients of this practice have the right to obtain a copy of paper or electronic medical records, make corrections to the record, request confidential communication, request that we limit the information we share, get a list of entities with whom we have shared your information, get a copy of this notice, choose someone to act on your behalf, and file a complaint if you believe your privacy rights have been violated.
Get a copy (paper or electronic) of your records. We will provide a copy of your record, and can charge you a reasonable, cost-based fee.
Ask us to correct your medical record. You can ask us to correct health information about you that you think is incomplete or incorrect.
Request preferred confidential communications.  You can ask us to contact you by a preferred method ( ie. Home/office/cell) or ask to send mail to a specified address.
Limit what we share or use. You can ask us not to share or use certain health information for our operations, treatment or payment, although we are allowed to refuse your request if it would affect your care.  If you pay for a service out of pocket in full, you can ask us not to share that with your health insurer, and we will comply unless a law requires us to share that information.
Get a list of those with whom we have shared information.  Upon request you are entitled to receive a list of the times we have shared your health information, who we shared it with, and why for up to six years prior to the date you asked.  We will include all the disclosures except those about treatment, payment and health care operations, and certain other disclosures, such as any you requested. There is no charge for a yearly   request of this list, but there is a reasonable cost based fee if such list is requested more than once in a 12 month period.
Get a hard copy of this privacy notice.   Upon request, you can receive a paper copy of this notice, if you have previously received this electronically.
Choose someone to act on your behalf. If someone is your legal guardian, or has medical power of attorney for you, that person can exercise your rights and make choices about your healthcare information. We will verify that any person has the authority to act on your behalf before taking any action.
File a complaint if you think your rights are violated.  If you feel your rights have been violated, please contact us (info on page 1). You can file a complaint with the US Dept of Health and Human Services Office of Civil Rights by visiting, calling 877.696.6775 or writing to:  US Dept of H and H Services, Office of Civil Rights, 200 Independence Avenue, S.W. Washington, D.C. 20201.  We will not retaliate against you for filing a complaint.

Your Basic choices and our basic responsibilities under HIPAA.  For certain health care information, you can tell us your choices about what we share. You can tell us whether to share information with your family, close friends, others involved in your care.  You can tell us whether to share information in a disaster relief situation.  We will never share your information for the sale of the information or for marketing purposes unless we have express written permission.  We can contact you in the case of fundraising, but you can tell us not to contact you again.

Our use and disclosures of your health information to treat you, run our practice or bill for your services.  We may use and share your health information to treat you and share with others who are treating you.  Ex – a child being treated by multiple therapists and disciplines.  We can use and share your health information to run our practice, improve your care and contact you when necessary.  We can use and share your health information to bill and get payment from health plans or other entities. Ex- we give information to your insurer so they will pay for our services.

Other ways we may share or use your health information.  We are required (upon request) to share your information in other ways that contribute to the public good, such as public health and research. These conditions are stringent and regulated by many laws before any information can be shared.
Help with safety and public health issues.  We can share health information about you for certain situations such as preventing disease, helping with product recall, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, preventing or mitigating a serious threat to someone’s health or safety. 
Do research. We can use or share your information for health research.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director. We can share information upon request when an individual dies.
Comply with the law, respond to any legal action. We will share information about you if state or federal law requires it, including any audits conducted by the Dept. of Health and Human Services. We can share information about you in response to a court or administrative order or in response to a subpoena.
Comply with worker’s compensation, law enforcement, other  gov’t requests.  Information about you can be shared for worker’s comp claims, law enforcement purposes, health oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services.
Blue Button protocol. Any patients with medical care managed by the Blue Button protocol can learn more about access to their health information at 

Summary of 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 will give you a hard copy of this notice and 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 that  we can.  You may also change your mind at any time and let us know in writing if you do.  Add’t info is available at:
Changes to the terms of this notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website and in our office.                     

POLICY / PROCEDURE for obtaining Authorization and Consent to Disclose 

Protected Health Information for Marketing and Promotional Purposes

PURPOSE:  The purpose of this policy is to establish guidelines to obtain and document the required authorization and/or release to photograph, interview, videotape, or otherwise record current and former patients, family members, employees or other individuals (hereinafter “Subject”) in compliance with HIPAA and applicable privacy laws.

POLICY STATEMENT: Bloom Physical Therapy and Wellness must obtain a written Release from every Subject prior to the Subject’s participation in any marketing or PR campaign, and any external news or media story, involving photographs, interviews, videotapes, or other recording. In addition to the Release, if the Subject is a patient, a patient’s family member, or other individual involved in a patient’s care or treatment, a Patient Authorization form must be completed by the patient, or patient’s personal representative, as appropriate, authorizing the use or disclosure of the patient’s Protected Health Information as part of the marketing or PR campaign, or in connection with an external news or media story. 

Bloom Physical Therapy and Wellness assumes no liability for the use of any photographs, interviews, videotapes, or recordings. The Subject providing the Release waives all rights to claims for payment in connection with any use of the photographs, interview material, videotape, or other recording.

PROCEDURE:  Before photographing, videotaping or recording a patient’s or patients’ family member or other individual in connection with the patient’s treatment [hereinafter “Subject(s)], Bloom Physical Therapy and Wellness shall:

  1. Explain the purpose of the requested release of the patient’s photographs, videotapes, recordings and/or associated protected health information to the Subject(s).

  2. Inform the Subject(s) that participation and authorization is voluntary and that treatment will not be conditioned on the Subject’s agreement to participate.

  3. Obtain the Subject’s agreement and signature on the HIPAA Authorization for Use and Disclosure of PHI for Marketing and/or Promotional Purposes 

  4. Obtain the Subject’s signature on the Consent for Use and Disclosure of Image, Voice, and/or Written Testimonials form.  (You must use both forms.)

  5. If the request involves participation by individuals other than the patient (e.g. as in the case of a recorded testimonial from a patient and a patient’s family member), a separate Release form must also be obtained from any other individual who will participate in the photograph, interview, videotape, or other recording. 

  6. The original, signed Patient Authorization and Release forms shall be maintained on file by Bloom Physical Therapy and Wellness for a minimum of six years. A copy of the patient’s Patient Authorization and Release should also be maintained in the patient’s medical record. 


Effective date:    5/21/2021
Privacy Officer:     Jessica Blaisdell                

Bloom Physical Therapy & Wellness

We help pregnant and postpartum women, and women in all stages of life get back to the activities they love without medication, surgery or just “living with it”.

Physical Therapy & Wellness

Concierge care serving Mahtomedi, MN and surrounding areas

Telephone: 651-395-7686