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Effective April 14th, 2003

DELTA DENTAL OF ILLINOIS NOTICE OF PRIVACY PRACTICES AND RIGHTS

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

PLEASE REVIEW THIS NOTICE CAREFULLY.

OUR PLEDGE REGARDING YOUR HEALTH

We are required by law to maintain the privacy of your health information. We are committed to protecting the confidentiality of your health information that we maintain and using your information appropriately.

We are also required to give you this Notice about our privacy practices.  This Notice explains how we may use your health information and when we can share that information with others. This Notice also informs you of your rights with respect to your health information and how you may exercise those rights.

We are required to follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices at any time provided that applicable law permits these changes. Before we make any change to our privacy practices that are described in this Notice, we shall amend the terms of this Notice and make this new Notice available to you. We reserve the right to make the new Notice effective for all health information we maintain including health information we created or received before we made the changes.

HOW WE MAY USE AND SHARE YOUR HEALTH INFORMATION

We are allowed to use or share health information about you for certain purposes without your authorization. The following categories describe different ways we use and disclose health information.  Not every use or disclosure in a category will be listed, but all of the ways we are permitted to use and disclose information will fall within one of the categories.

Payment: We may use and disclose your protected health information to determine eligibility for dental benefits, to collect premiums, to process claims for predetermination and payment for treatment you receive from dental providers, to determine benefits under your group dental plan or program, and to coordinate benefit coverage. We may also disclose health information to another entity subject to the federal health information privacy laws and regulations or to a health care provider for the payment activities of that entity or provider.

For example, we may use or disclose information about the treatment you received from a dentist in order to pay you or your dentist for covered services.

Health Care Operations:  We may use or disclose your health information for our health care operations for the following purposes: quality assessment and improvement activities, training, licensing, or credentialing activities, and health care fraud and abuse detection and compliance programs. We may also disclose your health information to another entity subject to the federal health information privacy laws and regulations. That disclosure may only be made if that entity has or has had a relationship with you and the health information pertains to that relationship.

For example, we may use health records to review participating dentists' treatment and services and to evaluate the performance of those dentists in caring for you.  We may combine health records about many of our enrollees to decide what additional services we should cover, what services are not needed, and to study the effectiveness of treatments. We may disclose information to our employees for training purposes.  We may also disclose information to national organizations that detect fraudulent billing.

Disclosure to Health Plan Sponsor, Which May Be Your Employer: Your health information may be disclosed to the sponsor of the health plan under which your dental benefits are provided solely for purposes of administering benefits under the health plan. The plan sponsor may be your employer or affiliated with your employer. Health information may also be disclosed to another health plan maintained by that plan sponsor for purposes of facilitating claims payments under that other health plan. We will make disclosures to the plan sponsor only if the plan sponsor has certified that it has put into place plan provisions requiring the sponsor to keep the health information protected.

We may, however, disclose certain health information to the plan sponsor without a certification in two circumstances. First, we may disclose summary health information to the plan sponsor to obtain premium bids or modifying, amending, or terminating the group health plan.  Summary health information is summary claims information that has been stripped of most information that can link it to particular individuals. Second, we may disclose information on whether you have enrolled in or disenrolled from your dental program.

We may also be required to release your health information, without your authorization, to others for the following reasons:

As Required By Law: We may report information to state and federal agencies that regulate us such as the U.S. Department of Health and Human Services and the Illinois Department of Insurance.

Public Health Activities:  We may share information to a public health authority that collects or receives information to prevent or control disease, injury or disability.

Victims of Abuse, Neglect or Domestic Violence:

We may report information to a government authority regarding child abuse, neglect or domestic violence.

Health Oversight Activities: We may share information with a health oversight agency for certain activities such as audits, inspections, licensure or disciplinary actions.

Lawsuits and Disputes: We may provide information to a court or an administrative agency, for example, pursuant to a court order or subpoena

Law Enforcement: We may report limited information to a law enforcement official for purposes, for example of identifying or locating a suspect, fugitive, material witness or missing person.

Coroners, Medical Examiners, and Funeral Directors: We may share information with a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law.  We may also share information with funeral directors as necessary to carry out their duties.

Avert a Serious Threat to Health or Safety:  We may report information to public health agencies if we believe there is a serious health or safety threat.  Any disclosure, however, would only be to someone able to help prevent the threat.

Specialized Government Functions: We may share information with armed forces personnel and authorized federal officials to facilitate specialized government functions, such as military and veterans activities and national security and intelligence activities.  We may also share your health information with the Department of State for use in making medical suitability determinations.

Workers' Compensation: We may release your health information for worker's compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Other Uses of Health Information

Other uses and disclosures of your health information not covered by this Notice or laws that apply to us will be made only with your written authorization.  If you give us an authorization, you may revoke that authorization, in writing, at any time to stop any future uses or disclosures. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your authorization.

WHAT ARE YOUR RIGHTS

You have the following rights regarding health information Delta Dental of Illinois maintains a bout you:

You have the right to inspect and copy your health records: You have the right to inspect and obtain a copy of the information that we maintain about you in your designated record set ("health records").  Your health records typically include claim and payment information. A request to inspect and copy these records should be made in writing to the Contract Compliance Department at Delta Dental of Illinois, 801 Ogden Avenue, Lisle Illinois 60532. If you request a copy of this information, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.  In certain situation, we may deny your request to inspect or obtain a copy of your information.  If we deny your request, we will notify you in writing and may provide you with a right to have the denial reviewed.

You have the right to ask us to make changes to your health records:  If you believe that any health information we have about you is incorrect or incomplete, you may ask us to make changes to this information.  These changes are known as amendments. You have the right to request an amendment for as long as the information is kept by or for us.

To request an amendment, your request must be made in writing and include a reason supporting the requested change. Please submit the request to the Contract Compliance Department at Delta Dental of Illinois, 801 Ogden Avenue, Lisle, Illinois 60532.  We may deny your request for an amendment if it is not in writing or does not include a reason.  We may also deny your request for amending your health information if it covers health records that:

We will respond to your request no later than 60 days after we receive it.  If we are unable to act within 60 days, we may extend that time by no more than an additional 30 days.  If we need to extend this time, we will notify you of the delay and the date by which we will complete action on your request.  If we make the change, we will notify you in writing that it was made. In addition, we will provide the amendment to any relevant person you have identified to be notified of the amendment. We will also notify any person that we know has the information that is the subject of the amendment and may rely on such information to your detriment.

You have the right to receive an accounting of certain disclosures: We must provide you with accounting of certain disclosures of your information made by us, if any, during the six years prior to your request. However, please note that we are not required to provide you with an accounting of the following information:

You must submit your request in writing to the Contract Compliance Department at Delta Dental of Illinois 801 Ogden Avenue, Lisle, Illinois 60532.  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.  We may charge you for the costs of providing an additional list. We will notify you of the cost involved and you may choose to withdraw or modify our request at that time before any costs are incurred.

You have the right to ask us to restrict the use or disclosure of your information: You have the right to ask us to restrict information about you that we use or disclose  for payment or health care operations. You also have the right to request us to restrict information that we may release to someone who is involved in your care or the payment for your care.

Please note that we are not required to agree to these restrictions. To request restrictions, you must make your request in writing to the Contract Compliance Department at Delta Dental of Illinois, 801 Ogden Avenue, Lisle, Illinois 60532.

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.

You have the right to ask to receive confidential communications of information: If you believe that you would be harmed if we send your health information to your current mailing address (for example, in situations involving domestic disputes), you can ask us to send the health information by alternate means (for example, by fax) or to an alternate address.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Delta Dental of Illinois c/o the Contract Compliance Department, 801 Ogden Avenue, Lisle, Illinois 60532, 630-964-2400.  All complaints must be submitted in writing.  You may also complain to the Secretary of the U.S. Department of Health and Human Services.   We will not retaliate against you for filing a complaint.

We will accommodate your reasonable requests to receive communications from us by alternative means or at alter native locations to the extent our claims management system has that capability.. Further, we will not ask you the reason for your request.  To request confidential communications, you must send a written request to the Contract Compliance Department at Delta Dental of Illinois, 801 Ogden Avenue, Lisle, Illinois 60532. Your request must specify how or where you wish to be contacted.

You have the right to receive a copy of this Notice upon request: 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 obtain a paper copy of this Notice from Delta Dental of Illinois upon request.

You may also obtain a copy of the current version of the Notice of Privacy Practice and Rights of Delta Dental of Illinois at its website: www.deltadentalil.com

FURTHER INFORMATION

You have a right to ask us questions about matters covered by this Notice. To do so, please contact the Contract Compliance Department at Delta Dental of Illinois, 801 Ogden Avenue, Lisle, Illinois 60532.  If you are calling in Illinois, the telephone number is 800-323-1743 (extension 4107); if you are calling outside of Illinois, the number is 800-452-1987 (extension 4107).