Privacy Practices and Rights

NOTICE OF PRIVACY PRACTICES AND RIGHTS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY

This notice is required by the Health Insurance Portability and Accountability Act (HIPAA) and federal regulations under HIPAA (together the "Privacy Rule"). We are required by the Privacy Rule to protect the privacy of your personal health information (“PHI”). We are also required to provide you with this notice which explains how we may use your PHI, when we can give out or "disclose" your PHI to others, and your rights regarding your PHI. PHI is defined as any individually identifiable information regarding a patient’s health care history, mental or physical condition, or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. We receive, use and disclose your PHI to administer your benefit plan or as permitted or required by law. Any other disclosure of your PHI without your authorization is prohibited.

We are required by law to follow the privacy practices in this Privacy Notice, but we reserve the right to revise or change our privacy practices and to make the revised or changed practices effective for PHI we already have about you as well as any information we receive in the future. If we make a material change to our privacy practices, we will notify you by direct mail or electronically as permitted by applicable law. In all cases, we will post the revised notice on our website, www.deltadentalwi.com.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that information about you and your health is personal. We are committed to protecting your PHI. This notice applies to all PHI that we maintain regarding you. Your personal dentist or health care provider may have different policies or notices regarding the dentist's use and disclosure of your medical information created in their office.

This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.

USE AND DISCLOSURE OF YOUR PHI

Permitted Uses and Disclosures of Your PHI Without Your Prior Authorization
The following categories describe the ways that we use and disclose your PHI as permitted by federal and state law without your prior authorization. We give examples for each category of use or disclosure. Not every use or disclosure in a category will be listed, but all of the ways we are permitted to use and disclose information will fall within one of the following categories.

For Payment (as described in applicable regulations).
We may use and disclose your PHI to determine eligibility for benefits, to facilitate payment for the treatment and services you receive from dentists, to determine coverage under your dental plan, or to coordinate coverage. For example, we may tell your dentist about treatments you have received so we can pay you or your dentist for covered services. We may use information about a treatment you are going to receive in order to provide prior approval or to determine whether your dental plan will cover the treatment. Likewise, we may share PHI with another entity to assist with the adjudication or subrogation of claims or to another health plan to coordinate benefit payments.

For Treatment (as described in applicable regulations).
We may use your PHI to facilitate dental or medical treatment for you. For example, we may disclose or use your PHI to determine eligibility for services requested by your provider or to discuss your treatment plan with your dentist.

For Health Care Operations (as described in applicable regulations).
We may use and disclose your PHI for health care operations. For example, we may use PHI in connection with conducting quality assessment and improvement activities; underwriting, premium rating, internal grievance resolution, and other activities relating to coverage; conducting or arranging for dental care review, legal services, audit services, and fraud and abuse detection programs; creating de-identified health information; business planning and development such as cost management; and business management and general administrative activities. We are, however, prohibited from using or disclosing genetic information for underwriting purposes.

We may share your PHI with third party “business associates” that perform various activities (for example, printing or mailing enrollment materials) for us. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.

• As Required By Law. We will disclose your PHI when required to do so by federal, state or local law. For example, we may disclose PHI when required by a court order in a litigation proceeding such as a malpractice action.

• To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose your PHI in a proceeding regarding the licensure of a dentist.

• Disclosure to Health Plan Sponsor, Which May Be Your Employer. Your PHI may be disclosed to the sponsor of the dental plan under which your benefits are provided solely for the purpose of administering benefits under the dental plan. The plan sponsor may be your employer or affiliated with your employer. PHI may also be disclosed to another dental or medical plan maintained by that plan sponsor for purposes of facilitating claims payments under that other health plan. We will make disclosures to the plan sponsor only if the plan sponsor has certified that it has put into place plan provisions requiring the sponsor to keep the PHI protected.

• We may, however, disclose certain PHI to the plan sponsor without a certification in two circumstances. First, we may disclose summary health information to the plan sponsor to obtain premium bids or to modify, amend, or terminate the group dental or medical plan. Summary health information is summary claims information that has been stripped of most information that can link it to particular individuals. Second, we may disclose information on whether you have enrolled in or disenrolled from your benefit program.

• For Other Products and Services. We may contact you without your written authorization to provide information regarding other health-related benefits and services that may be of interest to you. For example, we may use and disclose your PHI without your authorization for the purpose of communicating to you about our dental insurance products that could enhance or substitute for existing coverage.

• Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI on foreign military personnel to the appropriate foreign military authority.

• Workers' Compensation. We may release your PHI for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

• Public Health Risks. We may disclose your PHI for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

• Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

• Research. We may use or disclose PHI to researchers when an institution's review board or special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the health information used in their research and determined that the researcher does not need to obtain your authorization prior to using your PHI for research purposes.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

• Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at the hospital; and
• in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

• Coroners, Medical Examiners and Funeral Directors. We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI to funeral directors as necessary to carry out their duties.

• National Security and Intelligence Activities. We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Uses and Disclosures We May Make Only With Your Authorization
We will make the following uses and disclosures of your PHI only with your written authorization:

• Uses and disclosures of PHI for marketing purposes.
• Uses and disclosures that constitute a sale of your PHI.

Except as indicated above under Permitted Uses and Disclosures of Your PHI Without Your Prior Authorization, we will not use or disclose your PHI without your prior authorization. Any required authorization will be obtained from you by us or by a person requesting your PHI from us. You can later revoke an authorization in writing to stop any future use and disclosure. If you revoke your permission, we will no longer use or disclose your PHI for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI that we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your plan benefits. To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed.

• Right to Amend. If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information for as long as it is kept by us. Your request must be made in writing and submitted to Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• is not part of the PHI kept by or for Delta Dental;
• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.
  
  

• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" where such disclosure was made for any purpose other than treatment, payment, or health care operations. You must submit your request in writing to Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481, stating the time period for which you wish the disclosures, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.
  
  

• Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a dental procedure that you had. We will consider your request but are not legally required to accept it. To request restrictions, you must make your request in writing to Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

• Right to Request Confidential Communications. 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 can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to Receive Notice of a Breach. You have the right to be notified if there is a breach of any of your unsecured PHI.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.deltadentalwi.com or you may contact the Delta Dental Privacy Official, P.O. Box 828, Stevens Point, WI 54481.
  
  

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health & Human Services. You may also visit the Office for Civil Right’s website at http://www.hhs.gov/ocr/privacy/hipaa/complaints. To file a complaint with us, contact Delta Dental Privacy Official, P.O. Box 828 Stevens Point, WI, 54481. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint.