Notice of Privacy Practices

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

If you have any questions about this Notice Please contract our Privacy Officer.

Travis A Bell DDS PLLC (336) 274-8386

Effective Date September 23, 2016                                                                       Revised: December 2, 2020

We are committed to protect the privacy of your personal health information (PHI).

This Notice of Privacy Practices (Notice) describes how we may use within our practice or network and disclose (share outside of our practice or network) you PHI to carry out treatment, payment or health care operations. We may also share your information for other purposes that are permitted by law. This Notice also describes your rights to access and control your PHI.

We are required by law to maintain the privacy of your PHI. We will follow the terms outlined in this Notice.

We may change our Notice, at any time. Any changes will apply to all PHI. Upon your request, we will provide you with any revised Notice by:

• Posting the new Notice in our office
• If requested, making copies of the new Notice available in our office or by mail.
• Posting the revised Notice on our website: www.travisbelldds.com

Your PHI may be used and disclosed by your dentist, or office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health/dental care services to you.

EXAMPLE: Your PHI may be provided to a physician/dentist to whom you have been referred for evaluation to ensure that the physician/dentist has the necessary information to diagnose or treat you. We may also share you PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your dentist, becomes involved in your care by providing assistance with your health care diagnosis or treatment.

We may use and disclose your PHI to obtain payment for services. We may provide your PHI to others in order to bill or collect payment for services. There may be services for which we share information with your dental plan to determine if the services will be paid for.

PHI may be shared with the following

• Insurance Companies
• Government agencies in order to assist with qualification of benefits.

EXAMPLE: You are seen at our practice for a procedure. We will need to provide a listing of services such as radiographs “X-rays” to your insurance company so that we may be paid for the procedure. We may at times contact your dental care plan to received approval PRIOR to performing certain procedures to ensure the services will be paid for. This will require sharing of your PHI.

• If required by law: The use of disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. For example, we may be required to report gunshot wounds or suspected abuse or neglect.
  
  
• Public health activities: The disclosure will be made for the purpose of controlling disease, injury or disability and only to public health authorities permitted by law to collect or receive information. We may also notify individuals who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
  
  
• Health oversight agencies: We may disclose protected health information to a health oversight agency for activities authorized by law., such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefits programs, other government regulatory programs and civil rights laws.
  
  
• Legal proceedings: To assist in any legal proceeding or in response to a court order, in certain conditions in response to a subpoena, or other lawful process.
  
  
• Police or other law enforcement purposes: The release of PHI will beet all applicable legal requirements for release.
  
  
• Coroners, funeral directors: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law
  
  
• Special government purposes: Information may be shared for nations security purposes, or if you are a member of the military, to the military under limited circumstances.
  
  
• Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

• Business Associates: Some services are provided through the use of contracted entities call “business associates”. We will always release only the minimum amount of PHI necessary so that the business associate can perform the identified services. We require the business associate(s) to appropriately safeguard your information. Examples of business associates include billing companies or transcription services.
  
  
• Health Information Exchange: We may make your health/dental information available electronically to other healthcare providers outside of our facility who are involved in your care.
  
  
• Treatment alternatives: We may provide you notice of treatment options or other health related services that may improve your overall health.
  
  
• Appointment reminders: We may contact you as a reminder about upcoming appointments or treatment.

• We may share your information with friends or family members, or other persons directly identified by you at the level they are involved in your care or payment of services. If you are not present or able to agree/object, the healthcare provider using professional judgment will determine if it is in your best interest to share the information. For example, we may discuss post procedure instructions with the person who drove you to the facility unless you tell us specifically no to share the information.
  
  
• We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
  
  
• We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts.

• Marketing
• Disclosures of for any purposes which require the sale of your information

All other uses and disclosures not recorded in this Notice will require a written authorization from you or your personal representative.

Written authorization simply explains how you want your information used and disclosed. Your written authorization may be revoked at nay time, in writing. Except to the extent that your doctor or this practice has used or released information based on the direction provided in the authorization, no further use or disclosure will occur.

You have certain rights related to your protected health information. All requests to exercise your rights must be made in writing. Please call the office (336) 274-8386 and speak with our privacy officer to obtain the written request document.

• This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. If requested we will provide you a copy of your records in an electronic format. There are some exceptions to records which may be copied and the request may be denied. We may charge you a reasonable cost-based fee for a copy of the records.

• You may request for this practice not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. We are not required to agree with these requests. If we agree to a restriction request, we will honor the restriction request unless the information is needed to provide emergency treatment.
  
  
• There is one exception: we must accept a restriction request to restrict disclosure of information to a health plan if you pay out of pocket in full for a service or product unless it is otherwise required by law.

• We will agree to reasonable requests. We may also request alternative address or other method of contact such as mailing information to a post office box. We will not ask for an explanation from you about the request.

• You may request an amendment of your health information if you feel that the information is not correct along with an explanation of the reason for the request. In certain cases, we may deny your request for an amendment at which time you will have an opportunity to disagree.

• This right applies to disclosures for purpose other than treatment, payment or healthcare operations. You have the right to obtain a listing of these disclosures that occurred after September 23, 2016. If you request more than one list within a 12-month period you may be charged a reasonable fee.

• You have the right to obtain a paper copy of this notice from us, upon request. We will provide you a copy of this Notice via email when you schedule your new patient appointment along with your new patient paper work. In an emergency situation we will give you this Notice as soon as possible.
  
  
• You have a right to receive notification of any breach of your protected health information.

If you think we have violated your rights or you have a complaint about our privacy practices, you can contact:

Travis A Bell DDS PLLC and request to speak with our HIPPA privacy officer (336) 274-8386

You may also complain to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

If you file a complaint, we will not retaliate against you for filing a complaint.

Travis A Bell DDS PLLC 526 N Elam Ave Suite 201 Greensboro, NC 27403 www.travisbelldds.com
Email: drtravisbell@gmail.com Phone 336-274-8386 Fax 336-274-8375