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Maine Dental Service
Corporation, d/b/a/ Delta Dental Plan of Delta Dental Plan of New Hampshire, Inc. Delta Dental Plan of Vermont, Inc. NOTICE OF PRIVACY PRACTICES
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Companies Issuing This Notice This Notice describes the privacy practices of Northeast Delta Dental, which is composed of Maine Dental Service Corporation, d/b/a/ Delta Dental Plan of Maine, Delta Dental Plan of New Hampshire, Inc. and Delta Dental Plan of Vermont, Inc. (collectively "Northeast Delta Dental") and any other third party which assists Northeast Delta Dental in the administration of your dental plan. The Purpose of This Notice Northeast
Delta Dental has always maintained the privacy of your personal
information. We are now required by law
to maintain the privacy of your personal information and to give you this
Notice of our privacy practices, our legal duties and your rights concerning
your private health information.
Northeast Delta Dental must follow the practices described in this
Notice as long as this Notice is in effect.
This Notice will take effect on If you have any questions regarding this Notice, or if you wish to receive another copy, please contact:
HIPAA Privacy Officer Uses and Disclosures of Your Health Information Northeast Delta Dental uses and discloses your personal health information for purposes of treatment, payment and healthcare operations. For example: Treatment: We may use or disclose your personal health information to a physician or other healthcare provider which is providing treatment to you. Healthcare Operations: We may use or disclose your personal health information in connection with the administration of your dental plan, including such operations as claims adjudication, professional review, underwriting, coordination of benefits with other plans providing coverage, fraud and abuse detection programs, audit services and other administration activities. Payment: Your medical information may be used or disclosed to determine and remit proper payment for covered services under your dental plan. Disclosures Required By Law: Northeast Delta Dental may use or disclose your health information when it is required to do so by law. For example, your health information may be disclosed to comply with a court order, an administrative order, a subpoena, a discovery request or other lawful process. Other Disclosures: Northeast Delta Dental does not use or disclose your personal health information for marketing purposes nor does it sell your information for any purpose. Any use of your personal health information for any purpose other than treatment, payment or healthcare operations or as required by law, will require your written authorization. You may revoke any such authorization. Special Situations Disclosure to Health Plan Sponsor: Your personal health information may be disclosed to the sponsor of your group dental plan for the purpose of administering benefits under the plan. Worker's Compensation: Northeast Delta Dental may provide your personal health information for worker's compensation or similar programs which provide benefits for work related injuries or illness. Your Rights Regarding Health Information About You You have the following rights regarding the personal health information we maintain about you: Right to Inspect and Copy: You have the right to inspect and copy your health information which Northeast Delta Dental maintains. To inspect and copy your health information, please contact the Privacy Officer at the address or telephone number given above. If you request a copy of information, we may charge a fee for the costs of copying, mailing or other supplies needed to fulfill your request. Right to Amend: If you feel your health information maintained by Northeast Delta Dental is incorrect or incomplete, you may ask to amend the information by contacting the HIPAA Privacy Officer at the address or telephone number listed above. You may request an amendment for as long as the information is maintained by Northeast Delta Dental. Your request may be denied if it does not include a reason to support the request. In addition, it may be denied if you request to amend information that:
4 is not part of the health information maintained by
Northeast Delta Dental; Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures" if any such disclosure was made for any purpose other than treatment, payment or healthcare operations. To request an accounting of disclosures, you must submit your request in writing to the HIPAA Privacy Officer listed above. Your request must state a time period which may not be longer than six (6) years and may not include dates prior to Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. However, we are not required to agree to your request. Your request to limit or restrict use of your health information must be made in writing to the HIPAA Privacy Officer listed above and the request must include the information you wish to limit, whether you wish to limit use, disclosure or both and to whom the limits may apply, for example, disclosures to your spouse. Right to Request Confidential Communications: You have the right to request that we communicate with you concerning your health information only in certain ways or at certain locations. For example, you may request that we only contact you at work or by mail. Any such request must be made in writing to the HIPAA Privacy Officer noted above. Where possible, we will accommodate all reasonable requests. Right to a Paper Copy of This Notice: Even if you have received this Notice electronically, you are entitled to receive a paper copy of this Notice. A request for a copy of the Notice should be sent to the HIPAA Privacy Officer at the address above. You may also obtain a copy of this at our website, www.nedelta.com. How to File a Complaint: If you believe your privacy rights have been violated
by Northeast Delta Dental, you may file a written complaint addressed to the
HIPAA Privacy Officer, Northeast Delta Dental, |