We may also use your PHI in the following ways:  
To tell you about or recommend possible treatment alternatives  
or other health-related benefits and services that may be of  
interest to you.  
To your family or friends or any other individual identified by  
you to the extent directly related to such persons involvement  
in your care or the payment for your care. We may use or  
disclose your PHI to notify, or assist in the notification of, a  
person responsible for your care, of your location, general  
condition or death. If you are available, we will give you an  
opportunity to object to these disclosures, and we will not make  
these disclosures if you object.  
This Joint Notice is being provided to you on behalf of LIBERTY  
Dental Plan (the “Plan”) (collectively referred to herein as We or  
Our). We understand that your medical information is private and  
confidential. Further, we are required by law to maintain the privacy  
of protected health information.” or “PHI” which includes any  
individually identifiable information that we obtain from you or  
others that relates to your past, present or future physical or mental  
health, the health care you have received, or payment for your health  
care. We will share PHI as necessary, to carry out payment or health  
care operations relating to the services to be rendered at the Plan  
When permitted by law, we may coordinate our uses and  
disclosures of PHI with public or private entities authorized by  
law or by charter to assist in disaster relief efforts.  
We may disclose information to the sponsor of our plan.  
As required by law, this notice provides you with information about  
your rights and our legal duties and privacy practices with respect to  
the privacy of PHI. This notice also discusses the uses and  
disclosures we will make of your PHI. We must comply with the  
provisions of this notice as currently in effect, although we reserve  
the right to change the terms of this notice from time to time and to  
make the revised notice effective for all PHI we maintain. You can  
always request a written copy of our most current privacy notice  
We may use your information for underwriting purposes;  
however, we will not disclose genetic information for this  
We may contact you as part of our marketing efforts as  
permitted by applicable law.  
We will use or disclose PHI about you when required to do so  
by applicable law.  
Note: incidental uses and disclosures of PHI sometimes occur and  
are not considered to be a violation of your rights. Incidental uses  
and disclosures are by-products of otherwise permitted uses or  
disclosures which are limited in nature and cannot be reasonably  
We can use or disclose your PHI for purposes of treatment, payment  
and health care operations. For each of these categories of uses and  
disclosures, we have provided a description and an example below.  
However, not every particular use or disclosure will be listed.  
Subject to the requirements of applicable law, we will make the  
following uses and disclosures of your PHI:  
Treatment means the provision, coordination or management of  
your health care, including consultations between health care  
providers relating to your care and referrals for health care from  
one health care provider to another. For example, we may  
release information to a provider to coordinate your care.  
Military and Veterans. If you are a member of the Armed  
Forces, we may release PHI about you as required by military  
command authorities. We may also release PHI about foreign  
military personnel to the appropriate foreign military authority.  
Payment means the activities we undertake to reimburse  
providers for the health care provided to you, including billing,  
collections, claims management, and other utilization review  
activities. For example, we may need to obtain PHI from your  
provider to determine whether the proposed course of treatment  
will be covered or if necessary to obtain payment.  
Public Health Activities. We may disclose PHI about you for  
public health activities, including disclosures:  
to prevent or control disease, injury or disability;  
to report births and deaths;  
to report child abuse or neglect;  
to persons subject to the jurisdiction of the Food and  
Drug Administration (FDA) for activities related to the  
quality, safety, or effectiveness of FDA-regulated  
products or services and to report reactions to  
medications or problems with products;  
Health care operations means the support functions of the Plan,  
related to treatment and payment, such as quality assurance  
activities, case management, responding to patient complaints,  
compliance programs, audits, business planning, development,  
management and administrative activities. For example we  
may combine PHI about many patients to decide what  
additional services we should offer. In addition, we may  
remove information that identifies you so that others can use  
the de-identified information to study health care and health  
care delivery without learning who you are.  
to notify a person who may have been exposed to a  
disease or may be at risk for contracting or spreading a  
disease or condition;  
to notify the appropriate government authority if we  
believe that an adult patient has been the victim of  
abuse, neglect or domestic violence. We will only make  
this disclosure if the patient agrees or when required or  
authorized by law.  
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.  
Health Oversight Activities. We may disclose PHI to federal or  
state agencies that oversee our activities (e.g., providing health  
care, seeking payment, and civil rights).  
3. You have the right to inspect and copy the PHI contained in our  
Plan records, except:  
Lawsuits and Disputes. If you are involved in a lawsuit or a  
dispute, we may disclose PHI subject to certain limitations.  
for information compiled in reasonable anticipation of,  
or for use in, a civil, criminal, or administrative action  
or proceeding;  
Law Enforcement. We may release PHI if asked to do so by a  
law enforcement official:  
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;  
In response to a court order, warrant, summons or  
similar process;  
To identify or locate a suspect, fugitive, material  
witness, or missing person;  
About the victim of a crime under certain limited  
About a death we believe may be the result of criminal  
About criminal conduct on our premises; or  
In emergency circumstances, to report a crime, the  
location of the crime or the victims, or the identity,  
description or location of the person who committed the  
(iii) for PHI contained in records kept by a federal agency or  
contractor when your access is restricted by law; and  
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  
In order 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, as well as other costs associated with your  
Coroners, Medical Examiners and Funeral Directors. We may  
release PHI to a coroner or medical examiner. We may also  
release PHI about patients to funeral directors as necessary to  
carry out their duties.  
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.  
National Security and Intelligence Activities. We may release  
PHI about you to authorized federal officials for intelligence,  
counterintelligence, other national security activities authorized  
by law or to authorized federal officials so they may provide  
protection to the President or foreign heads of state.  
You have the right to request an amendment to your PHI but we  
Serious Threats. As permitted by applicable law and standards  
of ethical conduct, we may use and disclose PHI if we, in good  
faith, believe that the use or disclosure is necessary to prevent  
or lessen a serious and imminent threat to the health or safety of  
a person or the public or is necessary for law enforcement  
authorities to identify or apprehend an individual.  
may deny your request for amendment, if we determine that the PHI  
or record that is the subject of the request:  
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;  
Note: Information related to treatment of HIV, substance  
abuse, or mental health diseases or genetic information may  
enjoy certain special protections under applicable state and  
federal law.  
is not part of your medical or billing records or other  
records used to make decisions about you;  
(iii) is not available for inspection as set forth above; or  
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. In order 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.  
Certain uses and disclosures of PHI will be made only with your  
written authorization, including uses and/or disclosures: (a) of  
psychotherapy notes (where appropriate); (b) for marketing  
purposes; and (c) that constitute a sale of PHI under the Privacy  
Rule. Other uses and disclosures of PHI not covered by this notice  
or the laws that apply to us will be made only with your written  
authorization. You have the right to revoke that authorization at any  
time, provided that the revocation is in writing, except to the extent  
that we already have taken action in reliance on your authorization.  
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.  
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.  
You have the right to receive a notification, in the event that  
there is a breach of your unsecured PHI, which requires notification  
under the Privacy Rule.  
If you believe that your privacy rights have been violated, you  
should immediately contact the Privacy Officer at  
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.  
This notice is effective as of November 1, 2016.