Effective April 14, 2003
DELTA DENTAL OF KENTUCKY
DENTAL CHOICE, INC.
NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices applies to Delta Dental of Kentucky and Dental Choice, Inc. operating as affiliated covered entities. We are committed to safeguarding the personal health information of you and your family.
We are required by law to maintain the privacy of your personal health information and to provide you with notice of our legal duties and privacy practices. We are required to abide by the terms of this notice so long as it remains in effect. We reserve the right to change the terms of this notice as necessary and to make any new notice effective for all protected health information maintained by us. Copies of revised notices will be mailed to all members covered by the plan. Copies may also be obtained by mailing a request to the person named at the end of this notice.
Uses and Disclosures of Your Personal Health Information
Your personal health information is protected by law. We restrict use and disclosure of personal health information to employees, business associates, and other individuals or entities as necessary to carry out treatment, payment, health care operations, and the other purposes as permitted by law and described in this notice.
Communications to You and Information on When We Need Your Written Authorization: We may communicate with you regarding your claims, premiums, or other things connected with your health plan. We may disclose your personal health information to you in the manner and for the purposes described in the “Your Rights” section of this notice. We may use and disclose your personal health information without your authorization for any of the purposes described in this notice. We will not use or disclose your personal health information for any other purpose without your written authorization. You may revoke your written authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosure made by us in reliance on your prior authorization while it was in effect.
Disclosures for Treatment. We will make disclosures of your personal health information as necessary for your treatment. For instance, your dentist may request personal health information that we hold in order to make decisions about your care.
Uses and Disclosures for Payment. We will use and disclose your personal health information as necessary for payment purposes. For example, we may use information regarding your dental procedures and treatment to process and pay claims, to determine whether services are covered, to assist other Delta Dental plans with your claims for out-of-state services, or to coordinate benefits with an insurance carrier that provides you with the same or similar benefits.
Uses and Disclosures for Health Care Operations. We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations which include credentialing health care providers, business management, accreditation and licensing, utilization review and management, assessing the quality of care that our participating dentists provide, quality improvement and assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating, and other functions related to your health benefits plan.
Family and Friends Involved in Your Care. We may disclose your personal health information to a family member, friend, or other person involved in your care if you provide us written authorization to do so or if you are unable to do so because of a medical emergency, accident, incapacity or similar situation and we determine that disclosure would be in your best interest. In these situations, we may disclose personal health information to the extent necessary for your health care treatment or payment.
Your Employer or Other Benefit Plan Sponsor. We may disclose personal 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 presenting a dental benefits proposal or to modify, amend, or replace your dental services coverage. We may also 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 benefits 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 personal health information.
Business Associates. Some of our services are performed through contracts with outside businesses, such as billing, printing, auditing, actuarial services, legal services, etc. At times it may be necessary for us to provide certain portions of your personal health information to one or more of these outside persons or businesses who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
Marketing and Communications to You about Our Products and Services. We will not use your personal health information to communicate with you about products or services that are not health or dental related without your authorization. We may communicate to you without your authorization about a health-related product or service (or payment for that product or service) that we provide. We may also 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 plan enrollees that add value to your plan but are not part of the plan. We may send newsletters, communicate with you face-to-face, and send promotional items of nominal value.
Other Permitted Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your personal health information without your authorization, such as:
· For public health and safety: We may disclose personal health information to the extent necessary to avert a serious and imminent threat to your or others’ health or safety. We may disclose personal health information to a government agency or contractor authorized to oversee the health care system, to public health authorities for public health purposes, and to the Food and Drug Administration in limited circumstances. We may disclose personal health information to appropriate authorities if we reasonably believe that you are a possible victim of crime, domestic violence, abuse, or neglect.
· As required by law: We may use or disclose personal health information for purposes required by law. We may disclose personal health information to state insurance and health regulatory authorities or when responding to a complaint that you have filed with these or similar government agencies. We may also disclose personal health information authorized by workers compensation or similar programs established by law.
· In response to legal or administrative proceedings and similar processes: We may disclose personal health information in response to a court or administrative order, subpoena, discovery request, garnishment, or other lawful proceeding when required by law.
· To law enforcement officers and agencies: We may disclose limited personal health information to law enforcement officers in response to court orders or legal processes about a suspect, fugitive, material witness, crime victim, or missing person. We may disclose personal 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 release your personal 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. We may also release personal health information to coroners or medical examiners as required by law.
· For military and national security: We may disclose to military authorities personal health information about armed forces personnel as required by law. We may release personal health information if necessary for national security and intelligence activities.
· For Research. In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a research organization may wish to compare outcomes of patients by payer source and will need to review a series of records that we hold. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board which oversees the research or by representations of the researchers that limit their use and disclosure of member information.
Your Rights
You have the right to:
Restrict Uses and Disclosures of Your Personal Health Information. You may request in writing that additional restrictions be placed on our use or disclosure of your personal health information. A restriction request form can be obtained from the person named at the end of this notice. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if appropriate. If we terminate an agreed-to restriction, we will notify you. You also have the right to terminate, in writing or orally, any agreed-to restriction.
Receive Confidential Communications About Your Personal Health Information. If you clearly state that the disclosure of all or part of your personal health information could endanger you, then you have the right to request that you receive communications from us regarding your personal health information by alternative means or at alternative locations. We will accommodate all reasonable requests. For instance, if you wish that messages not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing to the person named at the end of this notice.
Access Your Personal Health Information. You have the right to copy and/or inspect the personal health information that we retain on your behalf except for information compiled for legal proceedings. All requests for access must be made in writing and signed by you or your representative. We may charge you a reasonable cost-based fee that includes only the cost of copying, time to copy, postage, and preparing a summary of the requested information if you request such a summary. You may obtain an access request form from the person named at the end of this notice.
Amend Your Personal Health Information. You have the right to request in writing that we amend or correct your personal health information that we maintain. We are not obligated to make all requested amendments but will carefully consider each request. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the request. If we make an amendment or correction that you request, we may also notify others who work with us and who have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from the person named at the end of this notice.
Receive an Accounting of Disclosures of Your Personal Health Information. You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Your request must be made in writing and signed by you or your representative. Request forms are available by contacting the person named at the end of this notice. The first accounting in any 12-month period is free; you may be charged a reasonable cost-based fee for any subsequent accounting you request within the same 12-month period.
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 contact the person identified at the end of this notice to obtain a printed copy.
Complaints. If you believe your privacy rights have been violated, you can file a complaint by sending a letter or e-mail to the privacy officer named at the end of this notice. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. We will not retaliate against you in any way if you choose to file a complaint with us or with the department.
If You Need Additional Information or Have Questions About Our Privacy Practices. If you have questions or need assistance regarding this notice or any of your rights, you may contact the person named at the end of this notice.
Effective Date. This Notice of Privacy Practices is effective April 14, 2003.
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:
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Delta Dental of Kentucky |
Telephone: (502) 736-5000 |