Delta Dental of Virginia is committed to safeguarding personal and privileged information. This notice will explain how we meet that commitment. This notice is provided in accordance with the requirements of the Virginia Insurance and Information and Privacy Act (Virginia Code Section 38.2-600 et seq.). The notice includes applicable July 1, 2001 changes to that act.

Our Collection Practices

We collect personal and privileged information to administer your dental benefits program. This information includes (but is not limited to) your name, address, social security number, and information about your dental history. You are the primary source of this information. However, we also collect information from a variety of other sources. These sources may include (but are not limited to):

• Your employer or group.
• Insurance agents, brokers and consultants who submit information on your behalf or on your group’s behalf.
• Dentists and other professionals who provide dental and related services and their office personnel.
• Other dental insurers, health insurers, HMOs, and similar organizations with which you may have other dental, hospital, medical or related coverage.
• This information typically comes from your application, group enrollment form, direct personal contact, correspondence, telephone, facsimile, or Internet communications.

Types Of Information That May Be Disclosed

Virginia law permits us to disclose certain types of information to you, your representative, or a third party. The types of information that may be disclosed are:

• “Personal information” is any individually identifiable information that is gathered in connection with your dental services program and from which judgments can be made about your character, occupation, health, or other personal characteristics. It includes an individual’s name, address, and “medical record information,” but does not include (a) “privileged information” or (b) any information that is publicly available.
• “Medical record information” is personal information that (a) relates to your physical or mental condition and your medical history or treatment and (b) is obtained from medical professionals or institutions, or from you, your family, or legal guardian.
• “Privileged information” is any individually identifiable information that relates to, is collected in connection with, or is collected in reasonable anticipation of a claim or civil or criminal proceeding.
• “Financial information” means “personal information” other than “medical record information” or health care payment records. Our Disclosure Practices

We may disclose personal or privileged information to third parties without your authorization as permitted by law. These are examples of third parties to which personal or privileged information may be disclosed:

• Agents, brokers and consultants who provide (a) us with information about you or (b) you with information about Delta Dental of Virginia or your group dental benefits program.
• Dentists, other professionals, and dental office personnel who submit claims on your behalf or from whom we obtain information to process your claims promptly and accurately. Companies that contract with us to perform insurance and insurance-related services (such as companies that write checks or mail identification cards, data processing subcontractors, and software maintenance or development consultants).
• Dentists and other non-employee professionals who review claims for us or who are involved with claims appeal.
• Other Delta Dental plans that provide services outside Virginia and other dental insurers, health insurers, HMOs, and similar organizations for the purpose of (a) coordinating benefits or (b) preventing, detecting, or prosecuting criminal activity, fraud, material misrepresentations, or material nondisclosure in connection with enrollment or insurance activities.
• Your employer or group for the purpose of explaining how we paid claims, carried out our other responsibilities under the group contract, or for audit purposes. Insurance regulatory, law enforcement and similar government authorities.

Your Right To Review Recorded Personal Information

You may submit a written request to us for access to your recorded personal information. Our address is in the last section of this notice. You must describe the information that you seek in reasonable detail. You should include your name, address, and identification number and identify your dentist and dates of service, if applicable. The information must be that which we can locate and retrieve in a reasonable time and manner. We may ask you for proper identification to safeguard your personal and privileged information.

Within 30 days of your request, we will:

• Inform you of the nature and substance of the recorded personal information in writing, by telephone, or by other oral communication.
• Permit you to see and copy, in person (by appointment only), our recorded personal information that pertains to you, or provide you with copies of this information by mail, whichever you prefer. If the information is in coded form, we will provide a written plain language explanation.
• Identify the persons to whom the personal information has been disclosed within the two years prior to your request. If their identities have not been recorded, we will provide you with the names of persons to whom this information is normally disclosed.
• Permit you to correct, amend, or delete your recorded personal information in the manner provided for in the next section “Your Right to Correct Recorded Personal Information.”

If your file contains medical record information, we may ask you to name a treating dentist or other medical professional to whom we can send the information so that he or she may explain it to you. Your rights of access to recorded personal information do not extend to privileged information.

Your Right To Correct Recorded Personal Information

You may request that we correct, amend, or delete recorded personal information that we have if you believe it is inaccurate or incorrect. You must make this request in writing. To assist us, you must describe the information that you wish us to correct in reasonable detail and explain why it is inaccurate or incorrect. You must include your name, address, and identification number. You should also identify your dentist and dates of service, if applicable.

Upon receipt of your written request, we will investigate the information you believe is incorrect or inaccurate. Within 30 days of our receipt of your written request to correct, amend, or delete any recorded personal information that we have, we will:

• Correct, amend, or delete the inaccurate or incorrect portion of your recorded personal information; or
• Notify you that we refuse to make the correction, amendment, or deletion; the reasons for our refusal; and your right to file a statement of protest.

If we make a correction, amendment or deletion, we will notify you that we have done so. We will also furnish the information to any person whom you have designated who, within the preceding two years, may have received the incorrect personal information. If you disagree with our refusal to correct, amend, or delete your information, you may send us a concise statement describing the information that you believe is correct, relevant, or fair, and the reasons why you disagree with our refusal to change it. When we receive this statement of protest, we will:

• Place it in our file with the disputed personal information so that anyone reviewing the information will have access to it;
• Clearly identify the disputed personal information and provide the statement along with the information in any subsequent disclosure; and
• Furnish the statement to any of the people whom you have designated who, within the preceding two years, may have received what you believe to be incorrect personal information.

Your right to correct, amend or delete recorded personal information does not extend to privileged information.

Your Right To Direct That Certain Financial Information Not Be Disclosed

You may direct that we not disclose financial information to nonaffiliated third parties except as permitted by Virginia Code Section 38.2-613. You may exercise this right at any time, and your directive remains in effect until it is revoked. You may exercise this right by contacting us at the address in the last section in this notice. Please provide us your name, address, and subscriber identification number. Even if you choose to exercise this right, we may still share financial information with a nonaffiliated third party if the information is necessary to provide dental services plan or insurance-related services or perform dental services plan or insurance-related functions for your employer, your group or you. These include (but are not limited to) the services and functions listed in the “Our Disclosure Practices” section of this notice. Virginia Code Section 38.2-613 permits these types of disclosures.

Our Privacy Policy

Delta Dental of Virginia believes in a subscriber’s right to privacy with regard to his or her dental services plan records and dental history. We support an individual’s right to access his or her records and information in our possession pertaining to claims submitted for care and services. In accordance with current federal and state regulations, we strive to protect this information and allow access to personal and privileged information to the limited extent necessary for treatment purposes, patient knowledge, claim needs and/or as legally required.

We do not disclose personal or privileged information (including financial information) about our subscribers or former subscribers to anyone, except as permitted by law. We restrict access to personal and privileged information (including financial information) to our employees, consultants, and outside vendors who need to know the information to provide products and services to our subscribers. We maintain physical, electronic, and procedural safeguards that comply with federal and state laws to guard against non-permitted and unauthorized disclosures. If you have any questions about our procedures or information maintained about you, please contact us at the following address (be sure to include your name, address, and subscriber identification number):

Delta Dental of Virginia
ATTN: Privacy Officer
4818 Starkey Road
Roanoke, VA 24018

You may also contact us by calling toll-free at: 800-237-6060.