NOTICE OF PRIVACY PRACTICES FOR Care Plus DENTAL PLANS, INC.

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.

USE AND DISCLOSURE OF HEALTH INFORMATION

Care Plus Dental Plans, Inc. (“Health Plan”) may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), for purposes of making or obtaining payment for your care and conducting health care operations. Health Plan has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE PURPOSES FOR AND CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Make or Obtain Payment. Health Plan may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, Health Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.

To Conduct Health Care Operations. Health Plan may use or disclose health information for its own operations to facilitate the administration of Health Plan and as necessary to provide coverage and services to all of Health Plan’s enrollees. Health care operations include such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Clinical guidelines and protocol development, case management and care coordination.
• Contacting health care providers and enrollees with information about treatment alternatives and other related functions.
• Health care professional competence or qualifications review and performance evaluation.
• Accreditation, certification, licensing or credentialing activities.
• Underwriting, premium rating or related functions to create, renew or replace health insurance or health benefits.
• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
• Business planning and development, including cost management and planning related analyses and formulary development.
• Business management and general administrative activities of Health Plan, including customer service and resolution of internal grievances.

For example, Health Plan may use your health information to conduct case management and utilization review, combine your health information with other Health Plan enrollees to set its quality improvement program agenda, perform provider credentialing activities or engage in customer service and grievance resolution activities.

For Treatment Alternatives. Health Plan may use or disclose your health information to a dentist, a physician or other health care provider providing you treatment for the purpose of evaluating your health, diagnosing medical conditions and providing treatment.

For Distribution of Health-Related Benefits and Services. Health Plan may use or disclose your health information to provide you with information on health-related benefits and services that may be of interest to you.

For Disclosure to the Plan Sponsor. Health Plan may disclose your health information to the plan sponsor, usually your employer, for plan administration functions performed by the plan sponsor on behalf of the Health Plan. In addition, Health Plan may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids from other Health Plans or modify, amend or, terminate the plan. Health Plan also may disclose to the plan sponsor information on whether you are participating in the group health plan or have enrolled or disenrolled from the group health plan.

When Legally Required. Health Plan will disclose your health information when it is required to do so by any federal, state or local law.

To Conduct Health Oversight Activities. Health Plan may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Health Plan, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings. As permitted or required by state law, Health Plan may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process. Reasonable efforts will be made to either notify you about the request or to obtain an order protecting your
health information.

For Law Enforcement Purposes. As permitted or required by state law, Health Plan may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if Health Plan has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.

In the Event of a Serious Threat to Health or Safety. Health Plan may, consistent with applicable law and ethical standards of conduct, disclose your health information if Health Plan, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health or safety of the public or another person.

For Specified Government Functions. In certain circumstances, federal regulations require Health Plan to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the President and others, and correctional institutions and inmates.

For Worker’s Compensation. Health Plan may release your health information to the extent necessary to comply with laws related to worker’s compensation or similar programs.


AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than as stated above, Health Plan will not disclose your health information other than with your written authorization. We will obtain your authorization prior to using your health information for marketing purposes and for any use or disclosure that constitutes a sale. If you authorize Health Plan to use or disclose your health information, you may revoke that authorization in writing at any time.


YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that Health Plan maintains:

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Health Plan’s disclosure of your health information to someone involved in the payment of your care. However, Health Plan is not required to agree to your request. If you wish to make a request for restrictions, please contact the compliance officer at (414) 778-5299.

Right to Receive Confidential Communications. You have the right to request that Health Plan communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that Health Plan only communicate with you at a certain telephone number or by e-mail. If you wish to receive confidential communications, please make your request in writing to the compliance officer at 11711 W Burleigh Street Wauwatosa, WI 53222. Your request must specify how or where you wish to be contacted. Health Plan will attempt to honor your reasonable requests for confidential communications.

Right to Inspect and Copy your Health Information. You have the right to inspect and copy your health information. A request to inspect and copy records containing your health information must be made in writing to the compliance officer at 11711 W Burleigh Street Wauwatosa, WI 53222. If you request a copy of your health information, Health Plan may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.

Right to Request Amendment of your Health Information. If you believe that your health information records are inaccurate or incomplete, you may request that Health Plan amend the records. That request may be made as long as Health Plan maintains the information. A request for an amendment of records must be made in writing to the compliance officer at 11711 W Burleigh Street Wauwatosa, WI 53222. Health Plan may deny the request if you do not include a reason that supports the amendment. The request also may be denied if your health information records were not created by Health Plan, if the health information you are requesting to amend is not part of Health Plan’s records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if Health Plan determines the records containing your health information are accurate and complete.

Right to an Accounting. You have the right to request a list of certain disclosures of your health information that Health Plan is required to keep a record of under the Privacy Rule and state law. The request must be made in writing to the compliance officer at 11711 W Burleigh Street Wauwatosa, WI 53222. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for time periods going back more than six (6) years. Health Plan will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable costbased fee. Health Plan will inform you in advance of the fee, if applicable.

Right to a Paper Copy of this Notice. You have a right to request and receive a paper copy of this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact the compliance officer at (414) 778-5299. A patient or a patient’s representative may also obtain a copy of the current version of the Notice here.

Right to Receive Notice of a Breach. You have the right to be notified if there is a breach of any of your unsecured PHI.

DUTIES OF HEALTH PLAN

Health Plan is required by law to maintain the privacy of your health information as set forth in this Notice and to provide you with this Notice of its duties and privacy practices. Health Plan is required to abide by the terms of this Notice, which may be amended from time to time. Health Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If Health Plan makes a material change to its policies and procedures, Health Plan will revise the Notice and will provide a copy of the revised Notice to you within sixty (60) days of the change. You have the right to express complaints to Health Plan and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to Health Plan should be made in writing to the compliance officer at11711 W Burleigh Street Wauwatosa, WI 53222. Health Plan encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

Health Plan has designated the Compliance Officer as its contact person for all issues regarding enrollee privacy and your privacy rights. You may contact this person at 11711 W Burleigh Street Wauwatosa, WI 53222 or (414) 778-5299.

EFFECTIVE DATE

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT the Compliance Officer at 11711 W Burleigh Street Wauwatosa, WI 53222 or (414) 778-5299.