Privacy Practices

  • Privacy Officer – Lucille Whitehouse, LICSW, CADC, LADC-I

    lucy@whitehousetherapy.org

    (203) 770-6147

    THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE

    USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

    PLEASE REVIEW IT CAREFULLY.

    Bloom Psychological Services provides psychotherapy and counseling services.

    When you receive care from the Practice, we will create a patient record, which can be paper, electronic, or both. The

    patient record has information about your medical and/or mental health history and status, your treatments, and your

    progress. It may also contain sensitive information such as treatment for substance abuse or HIV.

    Who Will Follow This Notice?

    • The Practice and your individual provider(s)

    • All other members of the Practice’s workforce

    Summary of Our Uses and Disclosures

    We may use and share your information without your consent to:

    • Treat you

    • Run our organization

    • Bill for your services

    • Help with public health and safety issues

    • Do research

    • Comply with the law

    • Work with a medical examiner or funeral director

    • Address workers’ compensation, law enforcement, and other government requests

    • Respond to lawsuits and legal actions

    Your Rights

    When it comes to your health information, you have certain rights. This section explains your rights and some of our

    responsibilities to help you.

    Get an electronic or paper copy of your medical record

    • You can ask to see or get an electronic or paper copy of your medical record and other health information we have

    about you. Ask us how to do this.

    • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may

    charge 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 incorrect or incomplete. Ask us how to do

    this.

    We may say “no” to your request, but we’ll tell you why in writing within 60 days.

    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 say “yes” to all reasonable requests.

    Ask us to limit what we use or share

    • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are

    not required to agree to your request, and we may say “no” if it would affect your care.

    • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the

    purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share

    that information.

    • Get a list of those with whom we’ve shared information.

    • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date

    you ask, who we shared it with, and why.

    • We will include all the disclosures except for those about treatment, payment, and health care operations, and

    certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will

    charge a reasonable, cost-based fee if you ask for another one within 12 months.

    Get a copy of this privacy notice

    • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice 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.

    • We will make sure the person has this authority and can act for you before we take any action.

    File a complaint if you feel your rights are violated

    or by phone at (203) 770-6147.

    • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a

    letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling (877) 696-6775, or visiting

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

    • We will not retaliate against you for filing a complaint.

    Your Choices

    For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we

    share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your

    instructions.

    In these cases, you have both the right and choice to tell us to:

    • Share information with your family, close friends, or others involved in your care

    • Share information in a disaster relief situation

    • Include your information in a hospital directory

    We may also share your information when needed to lessen a serious and imminent threat to health or safety.

    We have no plans to share your information for the following purposes, but be assured that we will never do so without

    your written permission:

    • Marketing purposes

    • Sale of your information

    • Most sharing of psychotherapy notes

    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 and give you a copy of it.

    • We will not use or share your information other than as described here unless you tell us we can in writing. If you

    tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

    For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

    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, in our office, and on our web site.

    Patient Acknowledgment of Receipt

    I am a patient of Bloom Psychological Services. I acknowledge that:

    • I have received the Notice of Privacy Practices (the “Notice”) from the Practice.

    • I have been provided an opportunity to review it.

    • I have asked any questions that I have about the Notice, and the questions have been answered to my

    satisfaction.

    • I fully understand the Notice and agree to its terms.

    Revised 11/12/2025.

  • GOOD FAITH ESTIMATE

    If you are paying for our services out-of-pocket, you have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.  Under the law, health care providers need to give patients who are “self-pay,” defined as those that do not have healthcare insurance or who choose not to use their healthcare insurance for our services, an estimate of their bill for health care items and services before those items or services are provided.

    • You have the right to receive a Good Faith Estimate for the total expected cost of
    your care from us upon request or when scheduling an appointment.  The Good Faith Estimate includes related costs like medical tests, prescription drugs, equipment, and other fees.

    • If you schedule an appointment at least 3 business days in advance, we will provide you with a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule an appointment at least 10 business days in advance, we will provide you with a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask us for a Good Faith
    Estimate before you schedule an appointment, which we will provide to you within 3 business days of your request.

    • If you receive a bill that is at least $400 more than our Good Faith Estimate, you can dispute the bill.

    For questions or more information about your right to a Good Faith Estimate, visit
    www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-
    800-985-3059.

    Revised: 11/11/2025.

  • All information contained on this site is educational in nature and is provided only as general information and is not medical or psychological advice. There is no existence or a professional relationship between the practitioner and viewer and any information contained does not constitute a guarantee, warranty, or prediction regarding the outcome of an individual using a healing method for any particular issue.

    The practitioner accepts no responsibility or liability whatsoever for the use or misuse of information contained on this site, including links to other resources. If any court of law rules that any part of this disclaimer is invalid, the disclaimer stands as if those parts were struck out. By continuing to explore this website you represent that you have read, understand and agree to the terms of this disclaimer.

    In consideration of my use of this website, I for myself, my heirs, personal representative or assigns, do hereby release, waive, discharge, and covenant not to sue Bloom Psychological Services as a company, or Lucille Whitehouse, the individual and excuse this entity/person from liability from any and all claims including negligence resulting in personal injury, accidents, or illnesses (including death) and property loss arising from use of this website.

    Assumption of Risk: Mental health treatment carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid such risks. I have read the previous paragraphs and I know and understand and appreciate these and other risks are inherent in the treatment I am participating in. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

    Indemnification and Hold Harmless: I also agree to indemnify and hold harmless Bloom Psychological Services and Lucille Whitehouse ts trustees, directors, officers, employees and agents from any and all claims, actions, suits, costs, expenses, damages and liabilities including attorney fees as a result of this use of this website and the information contained within.