We're committed to protecting your health information.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

PROTECTING YOUR HEALTH INFORMATION

Washington Dental Service is committed to protecting the privacy and the confidentiality of your health information. We recognize that you depend on us to safeguard your personal information and uphold your privacy rights. This document – which is based on state and federal law — describes our commitment to preserve the privacy and confidentiality of your health information. This notice explains our privacy practices, our legal requirements and your rights regarding your protected health information (PHI).

Our Privacy Practices

This notice protects the rights of both current and former members of Washington Dental Service. It explains how we use your information and when we may share that information with others. It provides you with your rights with respect to your health and/or dental information and how you may exercise those rights. By law, we are required to send you this notice so that you are aware of how we maintain the privacy of your information.

Washington Dental Service employees are required to comply with our company policies and procedures to protect the privacy and confidentiality of your health and/or dental information. Violations identified or reported to Washington Dental Service are reviewed, and disciplinary and/or corrective actions are taken — when appropriate. Access to information by our employees is limited to a business “need-to-know” basis. For example, WDS employees need specific information to make benefit determinations, process claims, perform internal assessments and provide certain customer service functions.

Washington Dental Service has physical, electronic and process safeguards in place to restrict access to your information. These safeguards include secured office facilities, locked filing cabinets and controlled computer network systems.

This notice applies to all applicable companies within the Washington Dental Service family, which includes businesses owned or controlled by Washington Dental Service. Should any of our privacy practices change, we reserve the right to change the terms of this notice and to make the new notice effective for all health and/or dental information that we maintain. We will provide you a copy of the revised notice and post the notice on our Web site.

Information Maintained at Washington Dental Service

The “information” or “health information” or “dental information” referred to in this notice includes demographic information that may identify you and that relates to your past, present or future physical or mental health and related health care services.

How We May Use or Share Your Information

The following describes how we may use or share your information:

For Treatment

Dental information may be shared with your dentist in order to help him or her provide you with the care you need.

For Payment

Your information may be used when paying your dental claims submitted to us by you or your dental care provider.

Health Care Operations

Certain dental information may be used or shared for necessary health care operations. These may include, but are not limited to, performing quality assessment and improvement activities, evaluating provider performance, performing auditing functions, resolving complaints and appeals, and making benefit determinations.

Business Associates

Your information may also be shared with other individuals or entities, known as business associates, that perform payment or health care operations on behalf of Washington Dental Service. We will not share your information with these business associates unless they agree in writing to protect the privacy of your information.

Communications

Your information may be shared with third-parties acting on behalf of Washington Dental Service in order to provide you with information about alternative treatments and programs or about dental-related products and services that may be of value to you. We may also inform you about enhancements, replacements or substitutions to your dental coverage.

Non-personally Identifiable Information

Information that is “de-identified” may be used or shared. Information is considered de-identified when it does not personally identify you. We may also use a “limited data set” that does not contain any information that can directly identify you. The limited data set is used only for purposes of research, public health matters or health care operations.

Employee Benefit Plan

Under certain circumstances, we may share limited information about you with the employee benefit carrier through which you receive benefits in order to perform administrative functions. Examples of information we may share include summary health information so that the carrier may obtain bids from other plans or modify, amend or terminate coverage with Washington Dental Service. We may share information related to your enrollment, disenrollment and/or participation in a Washington Dental Service plan. Detailed information is not shared with your benefit carrier unless it agrees to maintain the privacy of your information.

Enrolled Dependents and Family Members

Generally, we will mail explanation of benefit (EOB) forms and other mailings containing PHI to the address we have on record for the subscriber of the dental plan. If you are unable to consent to the disclosure of your PHI, such as in an emergency situation, we may disclose your PHI to a family member or a friend to the extent necessary to help with your dental care. We will do so only if we determine that the disclosure is in your best interest. For a minor, we may disclose PHI to parents or guardians, consistent with state law.

Special Circumstances and State and Federal Laws

In special situations and under certain state and federal laws, we are required to use or release your health information. Examples of these events include, but are not limited to, the following:

· To comply with state and federal laws that require us to release your health information to others;

· To report information to state and federal agencies that regulate our business;

· To assist with public health activities;

· To report information to public health agencies if we believe there is a serious threat to your health and safety or that of another person or the public;

· To report activities to health oversight agencies;

· To assist court or administrative agencies;

· To support law enforcement activities;

· To comply with law enforcement agents for the purpose of identifying or locating a fugitive, material witness or missing person;

· To assist correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official;

· To report information to a government authority regarding child abuse, neglect or domestic violence;

· To share information with a coroner or medical examiner as authorized by law;

· To report information regarding job-related injuries as required by workers’ compensation laws;

· To share information related to specialized government functions;

· To assist researchers when the research has been approved by an institutional board that has approved the research proposal and established protocols to ensure the privacy of your information; or

· To a family member or friend under the following circumstances:

o If you provide verbal agreement to allow such disclosure

o If you are given an opportunity to object to such disclosure and you do not raise an objection; or

o If it can be inferred from the circumstances, based on Washington Dental Service’s professional judgment, that you would not object

Written Permission to Use or Share Your Information

For activities or purposes other than those noted above or as otherwise permitted by law, we must obtain your written permission – known as an authorization – prior to using or sharing your health information. If you sign an authorization, you may change your mind at any time and revoke your authorization in writing.

Once the authorization is revoked, we will no longer use or share the information as outlined in the authorization. However, be aware that we may not be able to retract information that was previously made based on a valid authorization.

Your Rights Regarding Your Protected Health Information

The following are your rights with regard to your PHI:

Right to Request Restriction on Use and Disclosure

You have the right to restrict how we use and share your information for treatment, payment or health care operations. You also have the right to ask to restrict your information that we have been asked to give to family members or to others who are involved in your care or payment for your care. Please note that we will try to grant your request, but we are not required to do so by law.

Right to Receive Confidential Communications

You have the right to request that we use a certain method to communicate with you about your PHI or that we send your PHI to an alternate location. If you advise us that disclosure of all or any part of your PHI could endanger you, we will comply with any reasonable request, provided you specify an alternate means of communication.

Right to Access Your PHI

You have the right to inspect and obtain a copy of the dental information we maintain in a designated record set. A designated record set refers to a group of records that includes enrollment, payment, claims determination or dental management activities. It also includes records that we use to make enrollment, coverage or payment decisions about you.

Your request to review and/or obtain a copy of your PHI records must be made in writing. We may charge a fee for the cost of producing, copying and mailing your requested information, but we will tell you the cost in advance. The right does not include a right to obtain copies of information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding. Furthermore, it does not include PHI that is subject to other state or federal laws that prohibit us from releasing such information. We may limit your access to PHI if we determine that providing the information could possibly harm you or another person. If we limit access based upon a belief that it could harm you or another person, you have the right to request a review of that decision.

Right to Amend Your PHI

You have the right to ask us to make changes to the information that we maintain about you in your designated record set. These changes are referred to as amendments. Amendment requests must be in writing and must include the reason for the request. We may deny your request for certain reasons, including if you ask us to change information that we did not create. If we deny your request to amend your records, we will provide you with a written explanation for the reason for denial. This written notification will explain your right to file a written statement of disagreement. In turn, we have a right to rebut your statement. You have the right to request that your initial written request, our written denial and your statement of disagreement be included with your health information for any future disclosures. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you have authorized, of the amendment and to include the changes in future disclosures of that information.

Right to an Accounting of Disclosures

You have the right to receive an accounting of certain disclosures of your health information made by us for up to six years prior to your request. Your request for an accounting must be made in writing and must state a time period for which you want an accounting. The time period may not be longer than six years and may not include dates before April 14, 2003. We will provide you with the date on which we made a disclosure, the name of the person or entity to which we disclosed your information, a description of the disclosure, the reason for the disclosure and other applicable information. If you request this list more than once in a 12-month period, we may charge you a reasonable fee for creating and sending those additional reports. We are not required to provide you with an accounting of disclosures of the following information:

• Any information collected prior to April 14, 2003;
• Information shared for treatment, payment or health care operations;
• Information already disclosed to you;
• Information shared as part of an authorization request;
• Information that is incidental to a use or disclosure that is otherwise permitted;
• Information provided for use in a facility directory;
• Information that was provided to persons involved in your care or for other notification purposes;
• Information shared for national security or intelligence purposes;
• Information that was shared or used as part of a limited data set for research, public health or health care operation purposes; or
• Information disclosed to correctional institutions, law enforcement officials or health oversight agencies.

Right to Paper Copy of This Notice

If you receive this notice on our Web site or by electronic mail (e-mail), you are also entitled to receive it in written form. Please contact Washington Dental Service using the information at the end of this notice to obtain a written copy of the notice.

QUESTIONS REGARDING USE AND DISCLOSURE OF YOUR PRIVACY RIGHTS

How to File a Privacy Complaint

If you believe that your privacy rights have been violated, you may file a complaint with Washington Dental Service by calling 1-206-985-5963. You may file a written complaint with Washington Dental Service by sending your complaint to:

Washington Dental Service

Attn: Compliance Officer

PO Box 75688

Seattle, WA 98125

You may also direct your complaints to the Secretary of the Department of Health and Human Services. Washington Dental Service will not penalize you or take any action against you for filing a complaint.

PROTECTING YOUR HEALTH INFORMATION

Washington Dental Service is committed to protecting the privacy of your health information. Washington Dental Service is required by federal and state law to maintain the privacy of your protected health information (“PHI”). This Notice refers to Washington Dental Service and Delta Dental Plan of Washington as “we,” “us” and “our.” This Notice explains our privacy practices, our legal duties, and your rights
concerning your PHI. PHI means any information that is identifiable to you as your health information, including information regarding your dental care and treatment, payment for your dental care or treatment, and identifiable factors such as your name, age, address and Social Security number. We will follow the privacy practices that are described in this Notice while it is in effect.

We collect PHI for a number of reasons, including to pay claims, determine your dental benefits, and to provide an explanation of benefits to you. We receive PHI from you, your employer or plan sponsor, and from dental care providers. For example, we receive PHI as a part of enrollment information and when dentists submit claims for reimbursement for covered benefits.

We protect your PHI by treating all your personal information that we collect as confidential. Our employees receive privacy training and have access to your PHI only when there is an appropriate reason, such as to administer your dental benefits or provide services to you. The amount of PHI our employees may access is the minimum necessary to perform their jobs. We only disclose PHI to a company that provides services to us or acts on our behalf if the company agrees to protect and maintain the confidentiality of your PHI. Physical, electronic and procedural safeguards that comply with federal and state regulations are maintained to guard your PHI.

USES AND DISCLOSURES WITHOUT YOUR AUTHORIZATION

We will not use or disclose PHI unless we are allowed or required by law. The main reasons for which we use or disclose your PHI are to evaluate and process requests for coverage and claims for benefits. The following are some examples of how we may use
or disclose your PHI without your authorization.

Treatment: We may use or disclose your PHI for treatment activities of a dental care provider. For example, we may inform you or your dental care provider about treatment alternatives or other benefits that may be offered under your dental benefit coverage. If your dentist refers you to another dental professional, we may disclose your PHI to that dental professional so that he or she can treat you.

Payment: We may use and disclose your PHI for our payment activities, including determining whether a specific treatment is a covered benefit, paying your dental benefit claims, and coordinating benefits with another health plan.

Health Care Operations: We may use or disclose your PHI for internal operations. For example, we may use your claims information to analyze data for cost control, planning, or fraud and abuse protection.

Business Associates: We may also share your PHI with third-party “business associates” who perform certain activities for us. We require these business associates to protect your PHI in the same way that we do.

Plan Sponsors: If you are enrolled in a group health plan, we may disclose your PHI to the plan sponsor to permit it to perform administrative activities.

Enrolled Dependents and Family Members: Generally, we will mail Explanation of Benefit (“EOB”) forms and other mailings containing PHI to the address we have on record for the subscriber of the dental plan. If you are unable to consent to the disclosure of your PHI, such as in an emergency, we may disclose your PHI to a family member or a friend to the extent necessary to help with your dental care or payment for your dental care. We will only do so if we determine that the disclosure is in your best interest. If you are a minor, we may disclose PHI to parents or guardians, consistent with state laws.

Other Permitted or Required Disclosures
 
As Required by Law: We must disclose PHI when required to do so by law.

Public Health Activities: We may disclose your PHI to public health agencies for reasons such as preventing or controlling disease, injury or disability.

Victims of Abuse, Neglect or Domestic Violence: We may disclose your PHI to government agencies about abuse, neglect or domestic violence.

Health Oversight Activities: We may disclose your PHI to government oversight agencies; for example, the state Insurance Commissioner, for activities authorized by law.

Judicial and Administrative Proceedings: We may disclose PHI in response to a court or administrative order. We may also disclose PHI in certain cases in response to a subpoena, discovery request, or other lawful process.

Law Enforcement: We may disclose PHI under limited circumstances to a law enforcement official for law enforcement purposes.

Coroners, Funeral Directors, Organ Donation: We may release PHI to coroners or funeral directors or in connection with organ or tissue donation.

Research: Under certain circumstances, we may disclose PHI about you for research purposes, provided certain measures have been taken to protect your privacy.

To Avert a Serious Threat to Health or Safety: We may disclose your PHI, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Special Government Functions: We may disclose PHI as required by military authorities or to authorize federal officials for national security intelligence activities.

Workers Compensation: We may disclose your PHI to the extent necessary to comply with state law for workers compensation programs.

OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION

Other uses or disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. If you sign an authorization, you may revoke it at any time in writing, although this will not affect information that we disclosed before you revoked the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have certain rights regarding PHI that we maintain about you. Right to Access Your PHI: You have the right to review and receive a copy of your PHI that is contained in records that we maintain for enrollment, payment, claims determination or dental management activities, or that we use to make enrollment, coverage or payment decisions about you. Your request to review and/or obtain a copy
of your PHI records must be made in writing. We may charge a fee for the cost of producing, copying and mailing your requested information, but we will tell you the cost in advance. The right does not include a right to obtain copies of information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and PHI that is subject to other state or federal laws that prohibit us to release such information. Also, we may limit your access to PHI if we determine that providing the information could possibly harm you or another person. If we limit access based upon a belief that it could harm you or another person, you have the right to request a review of that decision.

Right to Amend Your PHI: You have the right to request that we amend your PHI. Your request must be in writing, and it must identify the information that you think is incorrect and explain why the information should be amended. We may deny your request for certain reasons, including if you ask us to change information that we did not create. If we deny your request to amend your records, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you want amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you have authorized, of the amendment and to include the changes in future disclosures of that information.

Right to an Accounting of Disclosures by Us: You have the right to receive a report of disclosures we or our business associates have made of your PHI. The list will not include our disclosures related to your treatment, our payment or health care operations, disclosures made to you or with your authorization, or certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. We will provide you with the date on which we made a disclosure, the name of the person or entity to whom we disclosed your PHI, a description of the PHI disclosed, the reason for the disclosure, and other applicable information. If you request this list more than once in a 12-month period, we may charge you a reasonable fee for creating and sending those additional reports.

Right to Request Restrictions on Use and Disclosure of Your PHI: You have the right to request that we restrict or limit how we use or disclose your PHI for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed in an emergency.

Right to Receive Confidential Communications: You have the right to request that we use a certain method to communicate with you about your PHI or that we send your PHI to a certain alternative location. If you advise us that disclosure of all or any part of your PHI could endanger you, we will comply with any reasonable request, provided you specify an alternative means of communication.

Right to Paper Copy of this Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are also entitled to receive this Notice in written form. Please contact us using the information listed at the end of this Notice to obtain the Notice in written form.

QUESTIONS AND COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services. For more information on how to file a written complaint, call the Privacy Officer at the number listed below. Your privacy is one of our greatest concerns and there is never any penalty to you if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Requests for forms, comments and complaints should be sent to:

Washington Dental Services
Attn: Privacy Officer
P.O. Box 75688
Seattle, WA 98125
Phone: (206) 985-5963
Fax: (206) 528-7373
E-mail: compliance@deltadentalwa.com

Changes to this Notice: We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. We also post a copy of our current Notice on our Website at www.deltadentalwa.com. You may request a copy of a Notice at any time by contacting us at the number above.