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CONTACTS

For questions about these notices, please call us at 866-530-9675.

You may also write to us at

Delta Dental of California
P.O. Box 997330
Sacramento, CA 95899-7330





HIPAA NOTICE OF PRIVACY PRACTICES




CONFIDENTIALITY OF YOUR HEALTH INFORMATION


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.

This notice is required by law to inform you of how Delta Dental and its
affiliates (“Delta Dental”) protect the confidentiality of your health care
information in our possession. Protected Health Information (PHI) is defined as
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. Delta
Dental receives, uses and discloses 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 follow the privacy practices described in this notice and federal and state
privacy requirements that apply to our administration of your benefits. Delta
Dental reserves the right to change our privacy practice effective for all PHI
maintained. We will update this notice if there are material changes and
redistribute it to you within 60 days of the change to our practices. We will
also promptly post a revised notice on our website. A copy may be requested
anytime by contacting the address or phone number at the end of this notice. You
should receive a copy of this notice at the time of enrollment in a Delta Dental
program and will be informed on how to obtain a copy at least every three years.
 

 


PERMITTED USES AND DISCLOSURES OF YOUR PHI

Uses and disclosures of your PHI for treatment, payment or health care
operations

Your explicit authorization is not required to disclose information about
yourself for purposes of health care treatment, payment of claims, billing of
premiums, and other health care operations. If your benefit plan is sponsored by
your employer or another party, we may provide PHI to your employer or plan
sponsor to administer your benefits. As permitted by law, we may disclose PHI to
third-party affiliates that perform services for Delta Dental to administer your
benefits, and who have signed a contract agreeing to protect the confidentiality
of your PHI, and have implemented privacy policies and procedures that comply
with applicable federal and state law.

Some examples of disclosure and use for treatment, payment or operations
include: processing your claims, collecting enrollment information and premiums,
reviewing the quality of health care you receive, providing customer service,
resolving your grievances, and sharing payment information with other insurers.
Some other examples are:

 * Uses and/or disclosures of PHI in facilitating treatment. For example, Delta
   Dental may use or disclose your PHI to determine eligibility for services
   requested by your provider.
 * Uses and/or disclosures of PHI for payment. For example, Delta Dental may use
   and disclose your PHI to bill you or your plan sponsor.
 * Uses and/or disclosures of PHI for health care operations. For example, Delta
   Dental may use and disclose your PHI to review the quality of care provided
   by our network of providers.  



OTHER PERMITTED USES AND DISCLOSURES WITHOUT AN AUTHORIZATION

We are permitted to disclose your PHI upon your request or to your authorized
personal representative (with certain exceptions) when required by the U. S.
Secretary of Health and Human Services to investigate or determine our
compliance with law, and when otherwise required by law. Delta Dental may
disclose your PHI without your prior authorization in response to the following:

 * Court order;
 * Order of a board, commission, or administrative agency for purposes of
   adjudication pursuant to its lawful authority;
 * Subpoena in a civil action;
 * Investigative subpoena of a government board, commission, or agency;
 * Subpoena in an arbitration;
 * Law enforcement search warrant; or
 * Coroner’s request during investigations.

Some other examples include: to notify or assist in notifying a family member,
another person, or a personal representative of your condition; to assist in
disaster relief efforts; to report victims of abuse, neglect or domestic
violence to appropriate authorities; for organ donation purposes; to avert a
serious threat to health or safety; for specialized government functions such as
military and veterans activities; for workers’ compensation purposes; and, with
certain restrictions, we are permitted to use and/or disclose your PHI for
underwriting, provided it does not contain genetic information. Information can
also be de-identified or summarized so it cannot be traced to you and, in
selected instances, for research purposes with the proper oversight.

Disclosures Delta Dental makes with your authorization

Delta Dental will not use or disclose your PHI without your prior written
authorization unless permitted by law. You can later revoke that authorization,
in writing, to stop the future use and disclosure. The authorization will be
obtained from you by Delta Dental or by a person requesting your PHI from Delta
Dental.  

 


YOUR RIGHTS REGARDING PHI

You have the right to request an inspection of and obtain a copy of your PHI.

You may access your PHI by contacting Delta Dental at the address at the bottom
of this notice. You must include (1) your name, address, telephone number and
identification number, and (2) the PHI you are requesting. Delta Dental may
charge a reasonable fee for providing you copies of your PHI. Delta Dental will
only maintain that PHI that we obtain or utilize in providing your health care
benefits. Most PHI, such as treatment records or x-rays, is returned by Delta
Dental to the dentist after we have completed our review of that information.
You may need to contact your health care provider to obtain PHI that Delta
Dental does not possess.

You may not inspect or copy PHI compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, or PHI that is
otherwise not subject to disclosure under federal or state law. In some
circumstances, you may have a right to have this decision reviewed. Please
contact Delta Dental as noted below if you have questions about access to your
PHI.

You have the right to request a restriction of your PHI.

You have the right to ask that we limit how we use and disclose your PHI,
however, you may not restrict our legal or permitted uses and disclosures of
PHI. While we will consider your request, we are not legally required to accept
those requests that we cannot reasonably implement or comply with during an
emergency. If we accept your request, we will put our understanding in writing.

You have the right to correct or update your PHI.

You may request to make an amendment of PHI we maintain about you. In certain
cases, we may deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we
may prepare a rebuttal to your statement and will provide you with a copy of any
such rebuttal. If your PHI was sent to us by another, we may refer you to that
person to amend your PHI. For example, we may refer you to your dentist to amend
your treatment chart or to your employer, if applicable, to amend your
enrollment information. Please contact the privacy office as noted below if you
have questions about amending your PHI.

You have rights related to the use and disclosure of your PHI for marketing.

Delta Dental agrees to obtain your authorization for the use or disclosure of
PHI for marketing when required by law. You have the opportunity to opt-out of
marketing that is permitted by law without an authorization. Delta Dental does
not use your PHI for fundraising purposes.

You have the right to request or receive confidential communications from us by
alternative means or at a different address.

Alternate or confidential communication is available if disclosure of your PHI
to the address on file could endanger you. You may be required to provide us
with a statement of possible danger, as well as specify a different address or
another method of contact. Please make this request in writing to the address
noted at the end of this notice.

You have the right to receive an accounting of certain disclosures we have made,
if any, of your PHI.

You have a right to an accounting of disclosures with some restrictions. This
right does not apply to disclosures for purposes of treatment, payment, or
health care operations or for information we disclosed after we received a valid
authorization from you. Additionally, we do not need to account for disclosures
made to you, to family members or friends involved in your care, or for
notification purposes. We do not need to account for disclosures made for
national security reasons, certain law enforcement purposes or disclosures made
as part of a limited data set. Please contact us at the number at the end of
this notice if you would like to receive an accounting of disclosures or if you
have questions about this right.

You have the right to get this notice by email.

A copy of this notice is posted on the Delta Dental website. You may also
request an email copy or paper copy of this notice by calling our Customer
Service number listed at the bottom of this notice.

You have the right to be notified following a breach of unsecured protected
health information.

Delta Dental will notify you in writing, at the address on file, if we discover
we compromised the privacy of your PHI.  

 


COMPLAINTS

You may file a complaint to Delta Dental and/or to the U. S. Secretary of Health
and Human Services if you believe Delta Dental has violated your privacy rights.
Complaints to Delta Dental may be filed by notifying the contact below. We will
not retaliate against you for filing a complaint.  

 


CONTACTS

You may contact Delta Dental at 866-530-9675, or you may write to the address
listed below for further information about the complaint process or any of the
information contained in this notice.

Delta Dental
P.O. Box 997330
Sacramento, CA  95899-7330

This notice is effective on and after January 1, 2016.

Note: Delta Dental’s privacy practices reflect applicable federal law as well as
known state law and regulations. If applicable state law is more protective of
information than the federal privacy laws, Delta Dental protects information in
accordance with the state law.

 


LANGUAGE ASSISTANCE

IMPORTANT: Can you read this document? If not, we can have somebody help you
read it. You may also be able to get this letter written in your language. For
free help, please call right away at the Member/Customer Service telephone
number on the back of your Delta Dental ID card, or 1-866-530-9675. (Spanish)

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a
leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por
favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se
encuentra al reverso de su tarjeta de identificación de Delta Dental o al
1-866-530-9675.

重要通知:您能讀懂這封信嗎?如果不能,我們可以請人幫您閲讀。 這封信也可以用您所講的語言書寫。如需幫助,請立即撥打登列在您的Delta Dental ID卡
背面上的會員/客戶服務部的電話,或者撥打電話 1-866-530-9675。(Chinese)  

 


LAST SIGNIFICANT CHANGES TO THIS NOTICE:

 * Clarified that Delta Dental does not use your PHI for fundraising purposes.
   Effective January 1, 2016
 * Clarified that Delta Dental’s privacy policy reflect federal and state
   requirements. – effective January 1, 2015
 * Updated contact information (mailing address and phone number) – effective
   July 1, 2013
 * Updated Delta Dental’s duty to notify affected individuals if a breach of
   their unsecured PHI occurs – effective July 1, 2013
 * Clarified that Delta Dental does not and will not sell your information
   without your express written authorization – effective July 1, 2013
 * Clarified several instances where the law requires individual authorization
   to use and disclose information (e.g., fundraising and marketing as noted
   above) – effective July 1, 2013  

 


DELTA DENTAL AND ITS AFFILIATES

Delta Dental of California offers and administers fee-for-service dental
programs for groups headquartered in the state of California.

Delta Dental of New York offers and administers fee-for-service programs in New
York.

Delta Dental of Pennsylvania and its affiliates offer and administer fee
for-service dental programs in Delaware, Maryland, Pennsylvania, West Virginia
and the District of Columbia. Delta Dental of Pennsylvania's affiliates are
Delta Dental of Delaware; Delta Dental of the District of Columbia and Delta
Dental of West Virginia.

Delta Dental Insurance Company offers and administers fee-for-service dental
programs to groups headquartered or located in Alabama, Florida, Georgia,
Louisiana, Mississippi, Montana, Nevada, Texas and Utah and vision programs to
groups headquartered in West Virginia.

DeltaCare USA is underwritten in these states by these entities: AL — Alpha
Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental
of California; AR, CO, IA, MA, ME, MI, MN, NC, ND, NE, NH, OK, OR, RI, SC, SD,
VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS,
MT, TN, WV — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH,
TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha
Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental
of New York, Inc.; PA — Delta Dental of Pennsylvania; VA — Delta Dental of
Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator
in all these states. These companies are financially responsible for their own
products. Dentegra Insurance Company.


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York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware,
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