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.

We collect, use and disclose information provided by and about you for health care/dental payment and operations, or when we are otherwise permitted or required by law to do so.

For Payment: We may use and disclose information about you in managing your account or benefits, and paying claims for medical/dental care you receive through your plan. For example, we maintain information about your premium and deductible payments. We may also provide information to a doctor/dentist’s office to confirm your eligibility for benefits or we may ask a doctor/dentist for details about your treatment so that we may review and pay the claims for your dental care.

For Health/Dental Care Operations: We may use and disclose medical/dental information about you for our operations. For example, we may use information about you to review the quality of care and services you receive, or to evaluate a treatment plan that is being proposed for you.

We may contact you to provide information about treatment alternatives or other health-related benefits and services. For example, when you or your dependents reach a certain age, we may notify you about additional programs or products for which you may become eligible, such as individual coverage.

We may, in the case of some group health plans, share limited health information with your employer or other organizations that help pay for your membership in the plan, in order to enroll you, or to permit the plan sponsor to perform plan administrative functions. Plan sponsors receiving this information are required, by law, to have safeguards in place to protect it from inappropriate uses.

As Permitted or Required by Law: Information about you may be used or disclosed to regulatory agencies, such as during audits, licensure or other proceedings; for administrative or judicial proceedings; to public health authorities; or to law enforcement officials, such as to comply with a court order or subpoena.

Authorization: Other uses and disclosures of protected health information will be made only with your written permission, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing. We will then stop using your information. However, if we have already used your information based on your authorization, you cannot take back your agreement for those past situations.
Your Rights
Under new regulations that will be effective in April 2003, you will have additional rights over your health/dental information. Under the new rules, you will have the right to:

• Request restrictions on certain uses and disclosures of your protected health/dental information. However, we are not required to agree to a requested restriction.
• Receive confidential communications of protected health/dental information, using reasonable alternative means or at an alternative address, if communications to your home address could endanger you.
• Inspect and copy protected health/dental information. To obtain a copy of such information, please send us a written request. You also have the right to amend the information if you believe it is incomplete or inaccurate. If we did not create the information, we will refer you to the source, such as your doctor/dentist.
• Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment or health care/dental operations, or the law otherwise restricts the accounting. We are not required to give you a list of disclosures made before April 14, 2003.
• If you have agreed to receive this notice electronically, you are still entitled to a paper copy upon request.
Complaints

If you believe your privacy rights have been violated, you have the right to file a complaint with us, and/or with the Federal Government. You will not be penalized for filing a complaint.
Copies and Changes
You have the right to receive an additional copy of this notice at any time.

We reserve the right to change the terms of this notice. A revised notice will be effective for information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever privacy notice is currently in effect. We will communicate any changes to our notice through subscriber newsletters, direct mail or our website, www.LIBERTYdentalplan.com.
Contact Information

If you want to exercise your rights under this notice, or if you wish to communicate with us about privacy issues, or to file a complaint with us, please contact our Member Services Department at (888) 703-6999.