Dr. Teresa G. Conley

TeresaConleyDDS_Transparent_Logo_boat

1306 West Corbett Avenue

Swansboro, NC, 28584

(910) 326-2030

Fax: (910) 326-3192

Mon-Thurs: 9am - 5pm

Friday-Sunday: Closed

Privacy Policy

Teresa G. Conley, DDS, PA
Notice of Privacy Practices

This notice describes how medical 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 contact the Privacy Officer.

Sabrina J. Ellenberger 910-326-2030

Effective Date: April 14, 2003                        Revised: August 8, 2023

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) your PHI to carry out treatment, payment or health care operations. We may also share your information for other purposes that are permitted or required 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.conleydentistry.com

Uses and Disclosures of Protected Health Information

We may use or disclose (share) your PHI to provide health care treatment for you. 

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

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

We may also share your PHI with people outside of our practice, which may provide medical care for you such as home health agencies.

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 health plan to determine if the service will be paid for.

PHI may be shared with the following:

Billing companies

Insurance companies, health plans

Government agencies in order to assist with qualification of benefits

Collection agencies

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

We may use or disclose, as-needed, your PHI in order to support the business activities of this practice which are called health care operations. 

EXAMPLES:

Training students, other health care providers, or ancillary staff such as billing personnel to help them learn or improve their skills.

Quality improvement processes which look at delivery of health care and for improvement in processes which will provide safer, more effective care for you.

Use of information to assist in resolving problems or complaints within the practice.

We may use and disclosure your PHI in other situations without your permission:

If required by law: The use or 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 benefit 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 meet 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

Medical research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Special government purposes: Information may be shared for national security purposes, or if you are a member of the military, to the military under limited circumstances.

Correctional institutions: Information may be shared if you are an inmate or under custody of law which is necessary for your health or the health and safety of other individuals.

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. 

Other uses and disclosures of your health information:

Business Associates: Some services are provided through the use of contracted entities called “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 information available electronically to other healthcare providers outside of our facility who are involved in your care. 

Fundraising activities: We may contact you in an effort to raise money or donation of items for a specific charity or event. You may opt out of receiving such communications.

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, treatment or the need for such appointments. We may also contact you for account balances and or needed information pertaining to your account. 

We may use or disclose your PHI in the following situations UNLESS you object.

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 not 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. 

The following uses and disclosures of PHI require your written authorization:

Marketing

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

Release of psychotherapy notes: Psychotherapy notes are notes by a mental health professional for the purpose of documenting a conversation during a private session. This session could be with an individual or with a group. These notes are kept separate from the rest of the medical record and do not include: medications and how they affect you, start and stop time of counseling sessions, types of treatments provided, results of tests, diagnosis, treatment plan, symptoms, prognosis.

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 any 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.

Your Privacy Rights 

You have certain rights related to your protected health information. All requests to exercise your rights must be made in writing. You can obtain the written request to release your dental record including account records by downloading from our website at  HYPERLINK “http://www.conleydentistry.com” www.conleydentistry.com, or obtaining a hard copy in person at our office upon request. 

You have the right to see and obtain a copy of your protected health information. 

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 have the right to request a restriction of your protected health information. 

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.

You have the right to request for us to communicate in different ways or in different locations. 

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. We do ask that we have at least three forms of contacting each patient (address, cell, home, work number, email address, or emergency contact person). 

You may have the right to request an amendment of your health information. 

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.

You have the right to a list of people or organizations who have received your health information from us. 

This right applies to disclosures for purposes other than treatment, payment or healthcare operations. You have the right to obtain a listing of these disclosures that occurred after April 14, 2003. You may request them for the previous six years or a shorter timeframe. If you request more than one list within a 12 month period you may be charged a reasonable fee. 

Additional Privacy Rights

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 the first day we treat you at our facility. 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.

Teresa G. Conley, DDS, PA PRACTICE POLICY NOTICE TO ALL PATIENTS

In order that we may serve our patients in the most efficient manner, the following policies are in effect:

Payment of all ESTIMATED deductibles and Co-Pay or ESTIMATED fee amounts are due at the time of service for each visit. * Please note: While we try our best to estimate your insurance deductible and / or copay amounts per visit, knowledge of your insurance coverage is YOUR responsibility. Please review YOUR insurance policy before beginning any major dental treatment and address any questions you may to YOUR insurance companies.  

All Explanation of Benefit Statements (EOB’s), on all patients must be delivered to our office within 30 days of the service in order for our office to submit claims to multiple insurance companies (Primary & Secondary), otherwise the responsible party of the account will be responsible for all fees.  Patients must ensure our office gets the EOB’s when more than one insurance plan is on file with us.  

Finance and billing charges may apply to all accounts unpaid after 30 days. 

A full 48 hour business day notice is required for canceled or re-scheduled appointments. You are able to leave a message after hours on our voice mail by following the prompts 910-326-2030. Please note: A $50.00 Broken appointment Fee per Patient will be applied without proper notice.

Patients who have missed two appointments without the 24 hour business day notice or have been consistently late for appointments will be seen on a stand-by basis only or risk being dismissed from the practice.  

If a patient arrives past the appointment time they risk the chance of not being seen on that day and the appointment will be viewed as a missed appointment. Please arrive on time, this ensures other patients may be seen on time.  

Children under the age of eighteen (18) MUST be accompanied on each visit by a parent or guardian for ALL dental services. NO EXCEPTIONS ALLOWED. 

Patients without their current month’s insurance card (if applicable) will not be seen unless our office can obtain eligibility verification from your insurance carrier.  

Failure to disclose other dental insurance (where applicable) is a violation of the North Carolina State Law. 

We require you to update our office of any changes in contact information, insurance coverage, or employer status at all times to best contact you, estimate fees, and submit insurance claims on your behalf.  We do require insurance changes at least 2 full business days prior to any appointment in order to better serve you.  Thank you for your prompt attention to these matters. 

We require all patients to have the acknowledgement of receipt of notice for Privacy Practices on file. 

Complaints 

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

Sabrina J. Ellenberger, Practice Administrator for Teresa G. Conley, DDS, PA. Office phone; 910-326-2030. Fax; 910-326-3192. Address; 1306 West Corbett Ave, Swansboro, North Carolina 28584.

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. 

This notice was published and becomes effective on April 13, 2003 or date practice adopted the Notice.

Teresa G. Conley, DDS, PA Notice of Privacy Practices updated 8/8/2023 Page  PAGE 4 of  NUMPAGES  4

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