Your Rights Under HIPAA

1. You have the right to request restrictions on our uses and disclosures of PHI. However, we are not required to agree to your request. To request a restriction, you may make your request in writing to the Privacy Officer.
2. You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to the Privacy Officer.
3. You have the right to inspect and copy the PHI contained in our Plan records, except:
   1. for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
   2. if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
   3. for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
   4. for PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of the information.
      
      To inspect or obtain a copy your PHI, you may submit your request in writing to the Privacy Officer. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, or other costs associated with your request.
      
      We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law
4. You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:
   1. was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
   2. is not part of your medical or billing records or other records used to make decisions about you;
   3. is not available for inspection as set forth above; or
   4. is accurate and complete.
      
      In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. To request an amendment to your PHI, you must submit your request in writing to the Privacy Officer, along with a description of the reason for your request.
5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for certain routine disclosures. To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
6. You have the right to receive a notice, if there is a breach of your unsecured PHI, which requires a notice under the Privacy Rule.

COMPLAINTS/CONTACT PERSON

If you believe that your privacy rights have been violated, you should immediately contact the Privacy Officer at:

Phone: 888-704-9833
Email: privacy@libertydentalplan.com
Fax: 888-273-2718
Online: https://www.libertydentalplan.com/About-LIBERTY/Compliance/Report-Compliance-Concerns.aspx

We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services.

If you have any questions or would like further information about this notice, please contact the Privacy Officer as noted above.