Notice of Privacy Practices

Effective 4/14/03

Revised 6/13/13

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.

If you have any questions about this notice, please contact Delta Dental Privacy Official at 800-544-0718.

Who Will Follow This Notice
This notice describes the medical information practices of Delta Dental of Iowa. ("Delta Dental") and that of any third party that receives medical information from or for us to assist us in providing your dental benefits.

Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the dental claims submitted for payment under your dental plan. This notice applies to all of the medical records we maintain. Your personal dentist may have different policies or notices regarding the dentist's use and disclosure of your medical information created in the dentist's office.

This notice is required by regulations (the "Privacy Rule") established under federal law (the Health Insurance Portability and Accountability Act, or "HIPAA"). This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes our obligations and your rights regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

We are also required to provide notice to you of a breach of your unsecured protected health information.

How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information, as permitted by federal and state law. For each category of uses or disclosures we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Payment (as described in applicable regulations). We may use and disclose medical information about you 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 Delta Dental can pay you or your dentist for covered services. Delta Dental 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 medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.

For Health Care Operations (as described in applicable regulations). We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to provide quality care to all subscribers and covered beneficiaries. For example, we may use medical information 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 or limited data sets; business planning and development such as cost management; and business management and general administrative activities, such as customer service, management activities related to privacy compliance, and providing data analysis for policyholders, plan sponsors or other customers, provided that medical information identifying you will not be disclosed in or with such data analyses.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. For example, we may disclose medical information 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 medical information about you 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 medical information about you in a proceeding regarding the licensure of a physician.

Special Situations
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you 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;
• in connection with certain research activities;
• 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 medical information 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.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you 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 medical information 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 on our premises; 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 medical information 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 medical information to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you 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 medical information about you 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.

Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your Plan benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010. 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 medical information, you may request that the denial be reviewed.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Delta Dental.

To request an amendment, your request must be made in writing and submitted to Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010. 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 medical information 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.

To request this list or accounting of disclosures, you must submit your request in writing to Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010. Your request must state a time period, 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 at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your case, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request.

To request restrictions, you must make your request in writing to Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010. 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 9010, Johnston, IA 50131-9010. 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 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.deltadentalia.com.

To obtain a paper copy of this notice, contact Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010.

Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website. The notice will contain on the first page, in the top right-hand corner, the effective date.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with Delta Dental or with the Secretary of the Department of Health and Human Services. To file a complaint with Delta Dental, contact Delta Dental Privacy Official, P O Box 9010, Johnston, IA 50131-9010. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Use of Protected Health Information for Marketing Purposes; Sale of Protected Health Information
Uses and disclosure of protected health information for marketing purposes and disclosures that constitute sale of protected health information require your written permission. 

Disclosures You Authorize
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

Disclosures to Your Family and Friends
We may disclose your medical information to a family member, friend or other person to help with your medical care or with payment for your medical care. We may use or disclose your name, location, and general condition, or assist in the identification, location and notification of a person involved in your care.

Disclosures to Your Employer or Group Health Plan Sponsor
We will not disclose your personal medical information to your employer or group health plan sponsor unless they have elected to sign a confidentiality agreement. We may disclose summary health information about members in your group health plan to the plan sponsor to use to obtain premium bids for the dental insurance coverage offered through your group health plan, or to decide whether to modify, amend or terminate your group health plan. The summary information we may disclose summarizes claims history, claims expenses, or types of claims experience by the members in your group health plan.

Use or Disclosure of Genetic Information
We are prohibited from using or disclosing genetic information for underwriting purposes.