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.

 

The only Protected Health Information (PHI) that Wolfpack maintains in its records is your Social Security Number, your name, your birth date and sometimes your address and telephone/fax number.  We ONLY use this Protected Health Information to maintain your eligibility records with the carrier.  We do not disclose this information to anyone else.

 

NOTICE OF PRIVACY PRACTICES

CONFIDENTIALITY OF YOUR HEALTH CARE INFORMATION

This notice is required by law to tell you how Delta and its affiliates (“Delta”) protect the confidentiality of your health care information in our possession.  Protected Health Information (PHI) is defined as any individually identifiable information regarding a patient’s medical/dental 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 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 must follow the privacy practices that are described in this notice, but also comply with any stricter requirements under federal or state law that may apply to Delta’s administration of your benefits.  However, we may change this notice and make the new notice effective for all of your PHI that we maintain.  If we make any substantive changes to our privacy practices, we will promptly change this notice and redistribute to you within 60 days of the change to our practices.  You may also request a copy of this notice from the privacy official at the plan headquarters that provides your benefits (refer to the Contact section at the end of this notice).  You should receive a copy of this notice at the time of enrollment in a Delta program, and we will notify you of how you can receive a copy of this notice every three years.

 

Permitted Uses and Disclosures of your PHI

 

We are permitted to use or Disclose your PHI without your prior authorization for the following purposes.  These permitted uses and/or disclosures for purposes of health care treatment, payment of claims, billing of premiums, and other health care operations.  If your benefit program is sponsored by your employer or another party, we may provide PHI to your employer or that sponsor for purposes of administering your benefits.  We may disclose PHI to third parties that perform services for Delta in the administration of your benefits.  These affiliates have implemented privacy policies and procedures and comply with applicable federal and state law. 

 

We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to notify or assist in notifying a family member, another person, or a personal representative of your condition, to assist in disaster relief efforts, and to report victims of abuse, neglect, or domestic violence.  Other permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial, administrative, or other law enforcement purposes, information about decedents to coroners, medical examiners and funeral directors, for research purposes, 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 for use in creating summary information that can no longer be traced to you.  Additionally, with certain restrictions, we are permitted to use and/or disclose your PHI for fundraising and underwriting.  We are also permitted to incidentally use and/or disclose your PHI during the course of a permitted use and/or disclose, but we must attempt to keep incidental uses and/or disclosures to a minimum.  We use administrative, technical, and physical safeguards to maintain the privacy of your PHI, and we must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish the purpose of the use and/or disclosure.

Examples of Uses and Disclosures of Your PHI for Treatment, Payment or Healthcare Operations.  Such activities may include but are not limited to: 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.

Disclosures Delta Must Make Without an Authorization.  We are required to disclose your PHI to you and 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 must 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.

Disclosures Delta Makes With Your Authorization.  Delta will not use or disclose your PHI without your prior authorization if the law requires your authorization.  You can later revoke that authorization in writing to stop any future use and disclosure.  The authorization will be obtained from you by Delta or by a person requesting your PHI from Delta.

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 Plan of California, PO Box 7736, San Francisco, CA 94120, Attn: Subscriber Services. (888)335-8227.  You must include (1) your name, address, telephone number and identification number and (2) the PHI you are requesting.  Delta may charge a reasonable fee for providing you copies of your PHI.  Delta 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 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 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 of California 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.  We will consider your request but are not legally required to accept it.  If we accept your request, we will put any limits in writing and abide by them except in emergency situations.  You may not limit the uses and disclosures that we are legally required or allowed to make. 

You have the right to correct or update your PHI.  This means that you may request an amendment of PHI about you for as long as we maintain this information.  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.  You have the right to request or receive confidential communications from us by alternative means or at a different address.  We will agree to a reasonable request if you tell us that disclosure of your PHI could endanger you.  You may be required to provide us with a statement of possible danger, a different address, another method of contact or information as to how payment will be handled.  You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.  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 or certain law enforcement purposes, disclosures made as part of a limited data set, incidental disclosures, or disclosures make prior to April 14, 2003.   You have the right to get this notice by E-Mail.  Even if you agreed to receive notice via e-mail, you also have the right to request a paper copy of this notice.

Complaints.  You may complain to us or to the U.S. Secretary of Health and Human Services if you believe that Delta has violated your privacy rights.  We will not retaliate against you for filing a complaint.

Contact.  You may contact the Privacy Department at Delta Dental of California, P.O. Box 7736, San Francisco CA 94120.  Attn: Subscriber Services.  (888)-335-8227

This notice is effective on and after April 14, 2003.