The Dental Studio of Brunswick

Privacy Policy

Introduction.  The Dental Studio of Brunswick (“Practice”) is required by both federal law (HIPAA) and state law to maintain the privacy of your Protected Health Information.  This Notice of Privacy Practices describes how Practice may use and disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control your Protected Health Information.  “Protected Health Information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 

Your Health Information Rights.Your Health Information Rights.

While the actual records that Practice maintains about you belong to it, under Maine law the information contained in Practice’s records belongs to you.  Under the HIPAA Privacy Rule (45 CFR Part 160 and Part 164) you have the following rights:

Right to Request Restrictions

You have the right to request a restriction or limitation on the PHI that Practice uses or discloses for treatment, payment, or health care operations. You also have the right to request a limit on the PHI that Practice discloses to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that Practice not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Privacy Officer at the address set forth at the end of this Notice. Practice is not required to agree to your request unless you are asking Practice to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and the information you wish to restrict pertains solely to a health care item or service for which you have paid Practice “out-of-pocket” in full. If Practice agrees, it will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments

If you paid out-of-pocket (or in other words, you have requested that Practice not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and Practice will honor that request.

Right to Copy of this Notice

You have the right to obtain a paper copy of this Notice of Privacy Practices upon request.

Right to Inspect and Copy

You have the right to inspect and obtain a copy of your PHI maintained by Practice. If Practice maintains your PHI in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. Practice will make every effort to provide access to your medical information in the form or format you request, if it is readily producible in such form or format. If your medical information is not readily producible in the form or format you request your medical information will be provided in either Practice’s standard electronic format or if you do not want this form or format, a readable hard copy form. Practice may charge you a reasonable, cost-based fee for the labor associated with copying and transmitting a paper copy of your PHI and for transmitting your PHI in electronic format.

Right to an Accounting of Disclosures

You have the right to obtain an accounting of certain disclosures of your PHI (not including routine disclosures for treatment, payment or healthcare operations, unless Practice maintains your PHI in an electronic health record). If Practice maintains your PHI in an electronic health record, then Practice must provide you with routine disclosures of PHI, including disclosures of treatment, payment or healthcare operations, for the 3-year period prior to the date of the request.

Right to Request Confidential Communications

You have the right to request that Practice communicate with you about your PHI in a certain way or at a certain location. For example, you can ask that Practice only contact you at home, at work, or by mail. To request alternative communications of your PHI, you must submit your request in writing to the Privacy Officer at the address set forth at end of this this Notice.

Right to Receive Notice of a Breach

You have the right to be notified in the event of a breach of any of your unsecured PHI.

Right to Revoke Specific Authorizations

You have the right to revoke any authorization that you have provided to Practice that permits Practice to use or disclose PHI except to the extent that action has already been taken in reliance upon that authorization.

Right to Amend PHI

You have the right to request, in a writing that provides a reason to support the requested amendment, that Practice amend PHI for as long as the PHI is maintained.

Practice’s Responsibilities. Practice is required to:

• Maintain the privacy of your PHI.
• Provide you with a notice as to Practice’s legal duties and privacy practices with respect to information Practice collects and maintains about you.
• Abide by the terms of this notice.
• Notify you if Practice is unable to agree to a requested restriction.
• Accommodate reasonable requests to communicate PHI by alternative means or at alternative locations.
• Notify you in writing if the confidentiality of your PHI has been breached. A breach occurs when there is an unauthorized use or disclosure that compromises the privacy or security of your PHI.

Practice reserves the right to change its privacy practices and to make the new provisions effective for all PHI that it maintains. Should Practice’s information practices change, it will provide you with a revised notice at the time of your next appointment. Practice will also post a copy of its current notice at its office and on its website.

IV. Examples of How Practice Will Use or Disclose Your Protected Health Information.  Your PHI may be used and disclosed by members of Practice’s staff and others outside of Practice’s office that are involved in your care and treatment for the purpose of providing services to you.  Your PHI may also be used and disclosed to enable Practice to be paid for the services it renders to you.

Following are examples of the types of uses and disclosures of your PHI that Practice is permitted to make.  These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by Practice.

Treatment

Practice will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. For example, to ensure continuity of care, Practice may disclose your PHI, as necessary, to specialist dentists or other healthcare providers, including those outside Practice’s office, who may be treating you.

Payment

Your PHI will be used, as needed, to obtain payment for services that it provides to you. For example, some health plans must make a determination that you are eligible for reimbursement for particular services before Practice can provide them to you and Practice must provide them with your PHI to enable them to make such a determination.

Healthcare Operations

Practice may use or disclose, as-needed, your PHI in order to support its own business activities. These activities include, but are not limited to, quality assessment activities, training and supervision of staff members, licensing, certification and conducting or arranging for other business activities.

Appointment Reminders & Treatment Alternative

Practice may use or disclose your PHI, as necessary, to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

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V. Uses and Disclosures That Practice May Make Unless You Object. In the following situations, Practice may disclose your PHI if it informs you about the disclosure in advance and you do not object.

Notification

Upon request, Practice may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.

Communication with family or other caregiver

Practice may disclose to a family member, other relative, close personal friend or any other person you authorize in writing, PHI relevant to that person’s involvement in your care or payment related to your care.

If you are present for, or otherwise available prior to, a notification or communication with family or another caregiver, and you have the capacity to make health care decisions, Practice may make the disclosure if you agree; or if it provides you with the opportunity to object and you do not object; or Practice reasonably infers from the circumstances that you do not object. If you are not present for the notification or disclosure, or the opportunity to agree or object cannot be provided because of your incapacity or an emergency circumstance, Practice may determine whether the disclosure is in your best interest and, if so, Practice may disclose to the designated person only that information that is directly relevant to the person’s involvement with your health care.

VI. Uses and Disclosures Not Requiring Your Authorization.  The federal privacy rules provide that Practice may use or disclose your PHI without your authorization in the following circumstances:

Food and Drug Administration (FDA)

Practice may disclose PHI to the FDA relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Worker’s compensation

Practice may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Public health

As required by law, Practice may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution

Should you be an inmate of a correctional institution Practice may disclose to the institution or agents thereof PHI necessary for your health and the health and safety of other individuals.

Law enforcement

Practice may disclose PHI for law enforcement purposes as required by law or in response to a valid search warrant or court order.

Criminal Activity

Practice may disclose your PHI if Practice believes that it constitutes evidence of criminal conduct that occurred on Practice premises. Practice may also disclose your PHI if it is required by applicable state law to report suspected child abuse or neglect or abuse of incapacitated adults or an injury that it believes may have been the result of an illegal act. Practice may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Legal Proceedings

Practice may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain situations, in response to a subpoena, discovery request or other lawful process.

Relating to Decedents

Practice may disclose PHI regarding an individual’s death to coroners, medical examiners or funeral directors consistent with applicable law.

As Required By Law

Practice may use or disclose your PHI to the extent that the use or disclosure is required by state or federal 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, Practice must make disclosures when required by the Department of Health and Human Services to investigate or determine Practice’s compliance with the requirements of the federal Privacy Rules.

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Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your PHI including use and disclosure of psychotherapy notes, use and disclosure for marketing purposes, disclosures that constitute a sale of PHI, and other uses and disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law as described in this Notice. You may revoke this authorization, at any time, in writing, except to the extent that Practice has already relied upon your authorization in making a disclosure.

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For More Information or to Report Complaints

If you wish to exercise any of the rights listed in Section II of this Notice, or if you have questions and would like additional information you may contact our Privacy Officer either in writing or by phone at:

The Dental Studio of Brunswick

Attn: Jacob Kieffer, D.D.S.

80 Pleasant Street

Brunswick, ME 04011

207-344-1999

Jacob.Kieffer@thedentalstudio.me

If you believe that your privacy rights have been violated, you may file a complaint with Practice’s Privacy Officer and with the Secretary of the United States Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201.  To file a complaint with Practice, please submit your complaint in writing to Jacob Kieffer, D.D.S. at the address listed above.  Practice will not retaliate against you for filing a complaint.

This notice was published and became effective on April 12^th, 2025.