Federal Notice of Privacy Practices / HIPAA


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.

“Protected health information” means, with few exceptions, individually identifiable health information that is transmitted or maintained in any form or medium. The Plan Administrator is committed to safeguarding your protected health information. We restrict use and disclosure of protected health information to a limited number of employees, business associates, and other individuals or entities that we have determined need to use or disclose the information for treatment, payment, health care operations, and the other purposes described in this notice.

We are committed to protecting our members’ rights as they relate to protected health information. We acknowledge that, when and as permitted by law, you have a right to:

  • Adequate notice about the uses and disclosures of your protected health information and our legal duties with respect to this information,
  • Request further restrictions on uses and disclosures of your protected health information, and
  • Access, amend, and receive an accounting of disclosures of your protected health information.

The following sections of this notice provide more complete information about our privacy practices, your rights, and our rights and duties with respect to this information.

Uses and Disclosures of Protected Health Information

In almost all cases, we may use and disclose protected health information for treatment, payment, and health care operations. For example, we may use and disclose protected health information:

  • To communicate with the dentist who provides, coordinates, or manages your care
  • To determine how much or whom we should pay for covered services
  • To coordinate benefits with an insurance carrier that provides you the same or similar benefits
  • To assess the quality of care that our participating dentists provide
  • For case management or to direct or recommend alternative treatments, therapies, providers, or provider locations.

When using or disclosing protected health information or when requesting protected health information from another covered entity, we make reasonable efforts to limit the protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. In addition, we may use or disclose protected health care information to individuals and entities for the purposes described below:

To you and with your written authorization: We may disclose your protected health information to you in the manner and for the purposes described in the “Your Rights” section of this notice. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us written authorization, you may revoke it at any time by notifying us of your revocation in writing. Your revocation will not affect any use or disclosure permitted by your prior authorization while it was in effect. Without your written authorization, we may not use or disclose your protected health information to any person or for any reason not permitted by law.

To your family and friends: We may disclose your protected health information to a family member, friend or other person if (a) you provide us written authorization to do so, or (b) you are unable to provide the required authorization because of a medical emergency, accident, or similar situation and we determine that disclosure would be in your best interest. In these situations, we may disclose protected health information to the extent necessary for your health care treatment or payment.

To your employer or other plan sponsor: We may disclose protected health information to your employer or other sponsor of your group dental plan. Without amending the plan documents and without your written authorization, we may disclose summary health information to your employer or other plan sponsor for the purpose of responding to a request for a dental services program proposal or to modify, amend, or replace your dental services coverage. In similar fashion, we may disclose to your plan sponsor information about whether you have been enrolled, are participating, or are no longer enrolled in the group health plan. Your plan sponsor’s dental services plan document may require or permit other uses and disclosures. Please ask your plan sponsor for a more complete explanation of the sponsor’s uses and disclosures of protected health information.

For underwriting, enrollment, and similar activities: We may receive protected health information from you, your insurance agent, or your plan sponsor’s health benefits consultant and use that information to underwrite, rate, enroll, renew, or respond to a request about your dental services program from any of these individuals or entities.

For marketing: We may use your protected health information for marketing in limited circumstances permitted by law. For example, we may use your name and address to communicate with you about a health-related product or service that we provide (or payment for that product or service). This means we may communicate with you about changes in our dental care networks; replacement of, or enhancements to, your dental services plan; and health-related products or services available only to dental services plan enrollees that add value to your plan but are not part of the plan. We may send you newsletters, communicate with you face-to-face, and send you promotional items of nominal value.

For research: We may use or disclose protected health information for research purposes in limited circumstances permitted by law. We may disclose the information for research purposes if, for example, there are plans in place to protect and destroy personal identifiers at the earliest possible moment, written assurances on limiting the uses of protected health information, and evidence that the research could not be conducted without access to and the use of protected health information.

For public health and safety: We may disclose protected health information to the extent necessary to avert a serious and imminent threat to your health or safety or the health and safety of others. We may disclose protected health information to a government agency authorized to oversee the health care system or government programs or contractors, and to public health authorities for public health purposes. We may disclose protected health information to appropriate authorities if we reasonably believe that you are a possible victim of crime, domestic violence, abuse, or neglect.

Required by law: We may use or disclose protected health information in limited circumstances required by law. For example, we may disclose your protected health information to the U. S. Department of Health and Human Services if the department requests information to determine whether we are complying with federal privacy laws. In addition, we may disclose protected health information to state insurance and health regulatory authorities conducting state insurance or health examinations or when responding to a complaint that you have filed with these or similar government agencies. We may also disclose protected health information when authorized by workers compensation or similar laws and regulations.

Legal proceedings and similar processes: We may disclose protected health information in response to a court or administrative order, subpoena, discovery request, garnishment, or other lawful proceeding under certain circumstances required by law. We may disclose protected health information to law enforcement officers in response to lawful processes like court orders, warrants, orders, and grand jury subpoenas.

Law enforcement: We may disclose limited protected health information to law enforcement officers about a suspect, fugitive, material witness, crime victim, or missing person. We may disclose protected health information about an inmate or other person in custody to a law enforcement officer or correctional officer under circumstances required by law. We may disclose protected health information when necessary to assist law enforcement officers to capture an individual who has admitted to participation in a crime or has escaped from custody.

Military and national security: We may disclose to military authorities protected health information about armed forces personnel under circumstances required by law. We may disclose protected health information to authorized officers for lawful intelligence, counter-intelligence, and other national security activities.

Your Rights

Request restriction of uses and disclosures of your protected health information: You may request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions. However, if we agree, we will abide by our agreement, except in situations in which the restricted information is needed for emergency treatment. To be effective, our agreement to further restrictions must be in writing and signed by our privacy officer. We may terminate an agreement to further restrictions if we inform you of our termination. The termination will be effective for information created or received after we have informed you of our termination.

Access your protected health information: You have a right to inspect and obtain a copy of your protected health information that we maintain in a designated record set, with limited exceptions. Your request to inspect or obtain copies of your protected health information must be in writing. You must send your request to our contact person listed at the end of this notice. We will act on your request no more than 30 days after we receive it. If we do not maintain the protected health information that you have requested but we know where it is maintained, we will tell where to send your request for access. We may discuss the scope, format, and other aspects of the request with you if the discussion is necessary for a timely response. If you request photocopies of protected health information, we will charge a reasonable cost-based fee that includes only the cost of copying, staff time to copy, postage, and preparing an explanation or summary of the requested information if you tell us in advance that you only want a summary. You may request copies of protected health information that we maintain in a format other than photocopies. We will respond in the format that you request if the protected health information is readily producible in that format. If you request a format other than photocopies, we may charge you a cost-based fee for providing the information in that format. You may get in touch with the contact person identified at the end of this notice for more information about access.

Amend your protected health information: You have the right to have us amend protected health information or a record about you in a designated record set for as long as the protected health information or record is maintained in the designated record set. You must make the request in writing, direct it to the contact person listed at the end of this notice, and explain why your information should be amended. We will act on your request for an amendment no more than 30 days after we receive it. We may extend the time to respond by no more than 30 days if we do so in the manner permitted by law. If we accept your request to amend the protected health information, we will make reasonable efforts to notify (a) people you identify to us as having received the protected health information and need the amendment and (b) other people, including business associates, that we know have the protected health information and may have relied, or could foreseeably rely, on the information to your detriment. We may deny your request for amendment if we did not create the protected health information that you wish to have amended or for other reasons. We will provide you a written explanation of our reasons if your request is denied. You may respond with a statement of disagreement. We will append your statement of disagreement to your protected health information or record if you ask us to do so.

Request an accounting of disclosures of your protected health information: You have a right to receive information about instances in which our business associates or we have disclosed your protected health information, with limited exceptions. The exceptions include information we disclose for treatment, payment, or health care operations and information we disclose to you or with your written authorization. You must make your request in writing and direct it to the contact person identified at the end of this notice. We will provide an accounting of disclosures from the effective date of the federal privacy rule (which is, in most cases, April 14, 2003) but for a period of no more than six years prior to the date on which the accounting is requested. The information may include the date on which the disclosure was made, the name and address (if we know the address) of the person or entity to which we disclosed protected health information, a description of the information that was disclosed, the reason for the disclosure, or other information that, by law, we may substitute for this information. We will act on your request for an accounting within 60 days after we receive it, unless we extend the time for an additional 30 days in the manner permitted by law. We will provide the first accounting in any 12-month period free of charge. We may impose a reasonable cost-based fee for any subsequent request for an accounting by the same individual within the same 12-month period. We will inform you about the fee in advance and permit you to avoid or reduce the fee by withdrawing or modifying your request for this subsequent accounting.

Receive confidential communications about your protected health information: You may request that we communicate with you about your protected health information by alternative means or at alternative locations. You must advise us that communication by this means or at this location is necessary to avoid endangering you. You must make the request in writing and direct it to the contact person identified at the end of this notice. We will accommodate your request if it is reasonable, specifies the alternative means or location, and permits us to collect premiums and pay claims required by your dental services plan.

Receive printed notices of our privacy practices: If you obtained this notice only from our website or by electronic mail, you have the right to a printed copy. Please get in touch with the contact person identified at the end of this notice to obtain a printed copy of this notice.

Obtain additional information about our privacy practices, exercise a right, or file a complaint: If you wish to ask a question about our privacy practices, exercise any right to which you are entitled under this section, or file a complaint about a privacy matter, you should contact the privacy officer identified at the end of this notice. You may also submit a written complaint to the U. S. Department of Health and Human Services. We will provide you with the appropriate address at the U. S. Department of Health and Human Services upon request. We will not retaliate against you in any way if you choose to file a complaint with us or with the department.

Our Rights and Other Duties

We are required by federal and state privacy law to make reasonable efforts to ensure the privacy of protected health information that we maintain. We are also required to provide you this notice of our privacy practices, your rights, and our rights and duties with respect to protected health information. We will adhere to the privacy practices described in this notice while it is in effect. This notice takes effect on April 14, 2003 or your effective date under our group dental services plan, whichever of the two dates is later.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided these changes are required or permitted by law. Any new terms of our notice will be effective for all protected health information that we maintain, including protected health information that we created before we make the changes. Before we make any material change in our privacy practices, we will change this notice and send the new notice to our dental services plan members who are enrolled at the time of the change. You may request a copy of this notice at any time.

Your Contact Person for Privacy Matters
For more information about our privacy practices, to exercise your rights under this notice, or to file a complaint about a privacy matter, you should contact us at:

Plan Administrator
Attention: Privacy Officer
PO Box 12806
Roanoke, Virginia 24028
Telephone: 800-237-6060