This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.

I. Uses and Disclosures for Treatment, Payment and Health Care Operations
Mosaic Bloom Counseling may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

"PHI" refers to information in your health record that could identify you.

"Treatment, Payment and Health Care Operations"
Treatment is when Mosaic Bloom Counseling provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another mental health provider.

Payment is when Mosaic Bloom Counseling obtains reimbursement for your health care. Examples of payment are when Mosaic Bloom Counseling discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of the practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and case coordination.

"Use" applies only to activities within the office, such as sharing, applying, utilizing, examining and analyzing information that identifies you.

"Disclosure" applies to activities outside the office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
Mosaic Bloom Counseling may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when Mosaic Bloom Counseling is asked for information for purposes outside of treatment, payment, and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes that your therapist has made about your conversation during a private, group, joint, or family counseling session. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Mosaic Bloom Counseling has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
Mosaic Bloom Counseling may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If the therapist has reasonable cause to suspect a child is an abused or maltreated child, or the therapist has reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or other person legally responsible for such child states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, the therapist must report such abuse or maltreatment to statewide central register of child abuse and maltreatment, or the local child protective services agency.

Health Oversight: If there is an inquiry or complaint about the therapist's professional conduct to the Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors, Mosaic Bloom Counseling must furnish to the Pennsylvania Commissioner of Professional and Occupational Affairs, your confidential mental health records relevant to this inquiry.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that Mosaic Bloom Counseling has provided you and/or the records thereof, such information is privileged under state law, and Mosaic Bloom Counseling must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. Your therapist must inform you in advance if this is the case.

Serious Threat to Health or Safety: Mosaic Bloom Counseling may disclose your confidential information to protect you or others from a serious threat of harm by you.

Worker's Compensation: If you file a worker's compensation claim, and the therapist is treating you for the issues involved with that complaint, then the therapist must furnish to the chairman of the Worker's Compensation Board records which contain information regarding your psychological condition and treatment.

IV. Patient's Rights and Licensed Clinical Social Worker's Duties
Patient's Rights:
Right to Request Restriction - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Mosaic Bloom Counseling is not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know you are seeing a therapist. Upon your request, Mosaic Bloom Counseling will send your bills to another address.)

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Mosaic Bloom Counseling may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, the therapist will discuss with you the details of the request and denial process.

Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Mosaic Bloom Counseling may deny your request. On your request, the therapist will discuss with you the details of the amendment process.

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section II of this Notice). On your request, the therapist will discuss with you the details of the accounting process.

Right to a Paper Copy - You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.


Licensed Clinical Social Worker's Rights:
Mosaic Bloom Counseling is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

Mosaic Bloom Counseling reserves the right to change the privacy policies and practices described in this notice. Unless Mosaic Bloom Counseling notifies you of such changes, however, the therapist is required to abide by the terms currently in effect.

If Mosaic Bloom Counseling revises the policies and procedures, we will provide you with a revision notice.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, please inform the owner of Mosaic Bloom Counseling. You may contact the owner, Marquita Bolden, LCSW at the following:

Marquita Bolden, LCSW
8302 Old York Road, Suite B1

Elkins Park, PA 19027
267-227-0122
mbolden@mosaicbloomcounseling.com

If you believe that your privacy rights have been violated you may file a complaint. You may send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You may write to:

Office for Civil rights
US Department of Health and Human Services
150 S. Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
email: ocrcomplaint@hhs.gov

You have specific rights under the Privacy Rule. Mosaic Bloom Counseling will not retaliate against you for exercising your right to file a complaint.

VI. Restrictions and Changes to Privacy Policy
Mosaic Bloom Counseling reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that  we maintain. Mosaic Bloom Counseling will provide you with a revised notice by notifying you.

TELETHERAPY CONSENT FORM 

(REQUIRED IN THE EVENT TELEHEALTH IS NECESSARY) 

Definition of Services: I hereby consent to engage in teletherapy with Mosaic Bloom Counseling.  Teletherapy is a form of mental health service provided via internet technology, which can include consultation, treatment, telephone conversations and/or education using interactive audio, video, or data communications. I also understand that teletherapy involves the communication of my medical/mental health information, both orally and/or visually. 

Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions. 

I understand that I have the following rights with respect to teletherapy: 

1.  I, the client, need to located in a state where my therapist is licensed at the time of the session. The exception to this rule is if I am physically located in a state that is under emergency order allowing licensed social workers to practice across state lines, and only for the duration of the emergency order. 

2.  I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. 

3.  The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the Acknowledgement of Privacy Policy I received at the start of my treatment with Mosaic Bloom Counseling.

4.  I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. 

5.  There is a risk that services could be disrupted or distorted by unforeseen technical problems. 

6.  In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my therapist believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area. 

7.  I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not improve, and in some cases may even get worse. 

8.  I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 988 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my therapist will recommend more appropriate services. 

9.  I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer/phone/tablet, telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the therapist to do the same on their end. 

I have read, understand and agree to the information provided above regarding teletherapy:

This document contains important information about resuming in-person psychotherapy services in light of the COVID-19 Pandemic. Please read it carefully and let your therapist know if you have any questions. 

Decision to Meet Face-to-Face 

You have the option of meeting in-person for psychotherapy sessions in the office. If there is a resurgence of the pandemic, or if other health concerns arise, Mosaic Bloom Counseling may require that we meet through telehealth/video conferencing.  If you have concerns about meeting through telehealth/video conferencing, we will talk about it first and try to address any concerns that you are holding.  If you decide at any time that you would feel safer staying with, or returning to, telehealth services, your therapist will respect that decision, as long as it is feasible and  clinically appropriate. 

Risks of In-Person Services 

Our view is that there is a risk of exposure to the coronavirus if we meet in person. Mosaic Bloom Counseling will follow all CDC guidelines to keep offices and adjoining areas disinfected, including use of a HEPA filter, and disinfecting regularly.  Please understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or any other public health risk), and you agree to waive all rights and claims against Mosaic Bloom Counseling and your therapist both jointly and severally for damages arising therefrom. This risk may increase if you travel by public transportation, cab, or ride-sharing service.

We are committed to keeping you, us, and all of our families safe from the spread of this virus. If you show up for an appointment and your therapist believes that you have a fever or other Covid-19  symptoms, or believe you have been exposed to Covid-19, the therapist will have to require you to leave the office immediately.  We can follow up with services by telehealth as appropriate. 

Notification of Covid-19 Positivity 

If you have tested positive for the coronavirus, your therapist may be required to notify local health authorities that you have been in the office. If your therapist has to report this, they will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. If the therapist tests positive for the coronavirus, they will notify you so that you can take appropriate precautions as you deem necessary. Although these steps will improve safety, it is impossible to guarantee any outcome with an invisible virus. Please let your therapist know if you have questions about these efforts.

Use of Waiting Room and Bathrooms

For now, we ask that you come to the office no earlier than 10 minutes prior to our appointment. If you have arrived earlier than 10 minutes before our appointment, please wait outside of the building, weather permitting. 

Wearing Masks

For now, Mosaic Bloom Counseling does not require that you wear a mask while in the office, including the hallways and waiting room.  If there is a resurgence of the pandemic, or if other health concerns arise, your therapist may require that you wear a mask while in the office, waiting room, and bathroom.  While masks are currently voluntary, if you request for your therapist to wear a mask during the session, they will do so. 

The above precautions will be adjusted, if additional local, state or federal orders or guidelines are published. If that happens, the content may be subject to change, and we will review the changes. 

Informed Consent 

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together. Your signature below shows that you agree to these terms and conditions.