I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

The Bell Practice, LLC (hereafter, The Bell Practice ) clinicians and their support staff 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.

• “Clinician” refers to any mental health professional who provides clinical services. At The Bell Practice  this includes both psychiatry staff and psychotherapists/counselors.

• “Treatment, Payment and Health Care Operations”

– Treatment is when your The Bell Practice  clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when the clinician consults with another health care provider, such as your family physician or another mental health professional.

– Payment is when The Bell Practice  obtains reimbursement for your healthcare. An example of payment is when your clinician 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 The Bell Practice  office practices. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case

management and care coordination.

• “Use” applies only to activities within The Bell Practice  such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of The Bell Practice  such as releasing, transferring, or providing access to information about you to other parties.

• “Consent” means that you give prior permission. You give The Bell Practice  consent to handle your PHI as outlined in this Notice when you sign the Patient Acknowledgement form.

II. Uses and Disclosures Requiring Authorization

Your The Bell Practice  clinician 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 instances when your clinician is asked for information for purposes outside of treatment, payment and health care operations, the clinician will obtain an authorization from you before releasing this information. The clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the clinician has made about conversations with you during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. 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) the clinician 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

Your The Bell Practice  clinician may use or disclose PHI without your consent or authorization in the following circumstances:

• Child abuse: If the clinician has knowledge of any child who is suffering from or has sustained any wound, injury, or disability, or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality, abuse, or neglect, the clinician is required by law to report such harm immediately to STATE Child Protective Services or to the judge having juvenile jurisdiction, or to the office of the sheriff or the chief law enforcement official of the municipality where the child resides. Also, if the clinician has reasonable cause to suspect that a child has been sexually abused, the clinician must report such information, regardless of whether the child has sustained any injury.

• Adult and domestic abuse: If the clinician has reasonable cause to suspect that an adult who is vulnerable physically, mentally, or emotionally has suffered abuse, neglect, or exploitation, the clinician is required by law to report such information to the Tennessee Department of Human Services.

• Health oversight: If a complaint is filed against the clinician with the STATE Board of Examiners in

Psychology (or other appropriate state Board of Examiners), the Board has the authority to subpoena

confidential mental health information from me relevant to that complaint.

Judicial or administrative proceedings: If you are involved in a court proceeding and a request

is made for information about the professional services that an The Bell Practice  clinician has provided you and/or the records thereof, such information is privileged under state law, and the clinician 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. The Bell Practice  clinician must inform you in advance if this is the case.

• Serious threat to health or safety: If you communicate to your clinician an actual threat of

bodily harm against a clearly identified victim, and the clinician has determined or reasonably

should have determined that you have the apparent ability to commit such an act and are likely to

carry out the threat unless prevented from doing so, the clinician is required to take reasonable

care to predict, warn of, or take precautions to protect the identified victim from your violent

behavior.

• Workers' compensation: If you file a worker's compensation claim, and the clinician is seeing

you for treatment relevant to that claim, the clinician must, upon request, furnish to your

employer or insurer, and to you, a complete report as to the claimed injury, the effect upon you,

the prescribed treatment, and estimate of duration of hospitalization, if any, and a statement of

charges.

IV. Patient's Rights and Clinician’s Duties

Patient’s Rights:

• Right to Request Restrictions You have the right to request restrictions on certain uses and

disclosures of PHI about you. However, the RCPS clinician is not required to agree to a restriction

that 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 that you are

seeing a clinician. Upon your request, your bills will be sent to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in

RCPS’s mental health and billing records used to make decisions about you for as long as the PHI is

maintained in the record. On your request, the RCPS clinician will discuss with you the details of the

request 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. The clinician may deny your request. On your request, the clinician 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

regarding you. On your request, the clinician 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 RCPS upon

request, even if you have agreed to receive the notice electronically.

Clinician’s Duties:

• RCPS is required by law to maintain the privacy of PHI and to provide you with a notice of its legal

duties and privacy practices with respect to PHI.

• RCPS reserves the right to change the privacy policies and practices described in this notice. Unless

RCPS notifies you of such changes, however, RCPS is required to abide by the terms currently in

effect.

• If RCPS revises its policies and procedures, RCPS will notify you by mail, phone, fax, or e-mail.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision an The Bell Practice  clinician makes about access to your records, or have other concerns about your privacy rights, you may contact the The Bell Practice  Privacy Officer at 207 451 0214.

If you believe that your privacy rights have been violated and wish to file a complaint with the The Bell Practice  office, you may send your written complaint to Privacy Officer, The Bell Practice , 19 Bridge Street Unit 9 Kittery, ME 03904. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Bell Practice ’s Privacy Officer can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. The Bell Practice  will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date and Changes to Privacy Policy

This notice will go into effect on 18/08/2025.

The Bell Practice  reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by The Bell Practice . The Bell Practice  will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice available at any of its offices. If needed, The Bell Practice  will also provide a revised notice by mail, e-mail, or fax. Additionally, the notice will be made available on The Bell Practice ’s website (thebellpractice.com).