Privacy Policy

43205 Woodward Avenue

Bloomfield Hills
, MI 48302
(248) 451-0600          Fax (248) 451-0700


Bloomfield Pediatric Care is committed to protecting and maintaining the privacy of your medical or other personal information that is provided to us.  The Notice of Privacy Practices applies to our employees and staff as well as affiliated services.  This notice describes how we may use and disclose information about you.


In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:

  • Your name, address, phone numbers, birthdate, social security number, and photo ID.
  • Insurance information, employer, and relatives’ names.
  • Information relating to your child’s medical history, including other physicians your child may have seen.

In addition, we will gather certain medical information about your child and will create a record of the care provided to your child.  Some information also may be provided to us by other individuals or organizations that are a part of your child’s medical care.


We may use and disclose personal and identifiable health information about your child for a variety of purposes.  All of the types of uses and disclosures of information are described in the following, but not every use or disclosure in a category is listed.

For Treatment:  We may use or disclose health information about your child to coordinate proper health care.

For Payment:  We may use or disclose health information about your child to your insurance company to bill for our services and to collect payment.  For example, we may need to give a payor information about your child’s current medical condition so that it will pay us for services rendered.  We may need to inform your payor of the treatment your child is going to receive in order to obtain prior authorization or to see if the service is covered.

For Health Care Operations:  We may use or disclose health information about your child for the general operation of our business.  For example, we may use your child’s information to review the performance and quality of services provided.

Disclosures as required by Law or Regulations:  We may disclose health information, including individually identifiable information about your child as required by State or Federal laws and Regulations relating to any or all of the following:

  1. Community/Public Health activities and reports such as disease control, abuse or neglect, and health/vital statistics.
  2. Administrative agency oversight for such things as audits, investigations, licensure, or determining cause of death.
  3. Court Order or other legal processes related to law enforcement or national security activities.  We may also release protected health information in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or secure a protective order.
  4. Military and Veteran reporting on members of the armed forces of U.S. or foreign military for activities deemed necessary by military command authorities.
  5. Organ procurement organizations and transplant centers as required by regulatory organizations.
  6. Worker’s compensation or similar programs, which provide benefits for work-related injuries or illnesses without regard to fault.
  7. Research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy will be adequately protected in the study, to prepare or analyze a research protocol and for other research purposes.

Other uses and disclosure:  We may use and disclose your child’s health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.


You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment and health care operation purposes.  You may also request that we limit our disclosures to persons assisting your care or payment for your care.  We will consider your request, but are not required by federal regulation to agree to your request.

You have the right to inspect and receive a copy of your child’s health information.  To inspect and receive a copy, you must submit your request in writing.  If you request a copy of the information, we may charge a reasonable fee for processing your request.

If you believe that information in your child’s record is incorrect or incomplete you may ask us to amend the information by adding a statement to your child’s health information.  You must make your request in writing and provide a reason that supports your request.  We may deny your request for an amendment if it is not in writing and does not include a reason.  In addition, we may deny your request if you ask us to amend information that:

  1. Was not created by us, unless the person or entity that created the information is no longer available.
  2. Is not part of the health information kept by us.
  3. Is not part of the information which you would be permitted to inspect and copy.
  4. Is accurate and complete.

You have the right to request an “accounting of disclosure”.  This is a list of the disclosures we made of your child’s health information.  To request this list, you must submit your request in writing to the Privacy Officer.  Your request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003.  If you ask for this information from us more than once every month, we may charge you a fee.

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you may ask that we only contact you at work or by mail.  To request confidential communications, you must make your request in writing.  Your request must specify how or where you wish to be contacted.

You have the right at any time to a paper copy of this Notice.


We reserve the right to change this notice at any time.  We reserve the right to change this notice effective for personal health information we have about your child as well as any information we receive in the future.  In the event there is a material change to the notice, the revised notice will be posted.  In addition, you may request a copy of the revised notice at any time.


If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer.  You will not be retaliated against or penalized by us for filing a complaint.

Other uses and disclosure of health information not covered by this Notice, law or regulation will be made only with your written authorization.  If you give us permission to use or disclose health information about your child, you may at any time revoke in writing that permission for future uses and disclosure.  You understand that any disclosure we have already made with your permission cannot be taken back.


Please contact office.