Delta Dental Privacy Practices

Effective Date of This Notice: April 14, 2003

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.

This Notice describes the privacy practices of Delta Dental Plan of Michigan, Delta Dental Plan of Ohio, Delta Dental Plan of Indiana, Renaissance Life and Health Insurance Company of America, Renaissance Health Insurance Company of New York, and Renaissance Systems & Services, LLC (collectively, "we" or "us"). These entities have designated themselves as a single affiliated covered entity for purposes of the federal privacy rules, and each has agreed to abide by the terms of this Notice and may share protected health information with each other as necessary for payment or to carry out health care operations, or as otherwise permitted by law.

Your Health Care Information is Protected

We are required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. We are committed to protecting your health information.

Reasons for Disclosure

For Payment

We may use or disclose health information about you to determine eligibility for plan benefits, obtain customer payment for benefits, process and pay your claims, administer plan responsibility for benefits, and to coordinate benefits. For example, payment functions may include reviewing submitted claims or determining whether a treatment is covered under your plan.

For Health Care Operations

We may use and disclose health information about you to administer necessary activities related to your coverage. For example, setting rates, conducting assessment and improvement activities; reviewing your treatment, fraud and abuse detection, and general administration.

Health-Related Benefits and Services

We may use or disclose health information about you to communicate to you about health-related benefits and services. For example, we may communicate to you about health-related benefits and services that add value to, but are not part of, your health plan.

Personal Representatives

We may use or disclose health information about you for the purpose of dealing with individuals who are involved in your care or the payment for your care. For example, we may disclose health information to an individual who has legal authority to make health care decisions on your behalf.


We may use or disclose health information about you for research purposes. If we do, we may be required to obtain an authorization from you for such use or disclosure.

Secondary Reasons for Disclosure

As Required By Law

For example, when required in a litigation proceeding such as a malpractice action, in regard to participation conditions for a health care provider in a public benefits program [e.g., Medicare] and/or as required by federal or state statute or regulation.

To Avert a Serious Threat to Health or Safety

For example, to prevent or lessen a serious and imminent threat to the health or safety of a person or the general public.

Military and Veterans

For example, if required by military command authorities.

Worker's Compensation

For example, as necessary to comply with worker's compensation or similar laws.

Public Health Risks

For example, to prevent or control disease, or report child abuse, domestic violence, or disease or infection exposure.

Health Oversight Activities

For example, to help health agencies during audits, investigations or inspections.

Lawsuits and Disputes

For example, in the course of any administrative or judicial proceeding.

Law Enforcement

For example, to identify or locate a suspect or to comply with a court order, a court-ordered warrant or a subpoena or summons issued by an officer of the court.

National Security and Intelligence Activities

For example, for military, national security, prisoner and government benefit purposes.

Disclosures to Plan Sponsors

For example, to help the sponsor of your group health plan administer your benefits.

We will use or disclose your health information only as described in this Notice. It is not necessary for you to do anything to allow us to disclose your health information as described here. If you want us to use or disclose your health information for another purpose, you must authorize us to do so; you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

Your rights regarding health information we maintain

Your Right to Inspect and Copy Your Health Information To inspect and copy such information, you must submit your request in writing. If you request a copy of the information, we may charge you a reasonable fee to cover expenses associated with your request.

Your Right to Amend Incorrect or Incomplete Information You may request that we change your health information, although we are not required to do so. If your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must make you request in writing. You also must provide a reason for your request.

Your Right to an Accounting of Disclosures We Have Made You may request an accounting of disclosures, although we are not required to provide an accounting of disclosures made for payment or health care operations or any other exceptions provided for by the HIPAA Privacy Rule. You must submit your request in writing. Your request should specify a time period of up to six years and may not include dates before April 14, 2003. We will provide one list per 12-month period free of charge; we may charge you for additional lists.

Your Right to Request Restrictions on Uses and Disclosures If you would like to make a request for restrictions, you must submit your request in writing. Although you have this right, we are not required to agree to the restrictions that you request.

Your Right to Request Confidential Communications Through a Reasonable Alternative Means or at an Alternative Location To request that we direct confidential communications to you in an alternative manner, you must submit your request in writing. We are not required to agree to your request.

Your Right to a Paper Copy of This Notice To obtain a paper copy of this Notice or a more detailed explanation of these rights, send us a written request. You may also obtain a copy of this Notice at one of our websites:

Changes to This Notice

We can amend this Notice of Privacy Practices at any time in the future and make the new Notice provisions effective for all health information that we maintain. We will promptly revise our Notice and distribute it to you whenever we make significant changes to the Notice. We are required by law to comply with the current version of this Notice.


Complaints about this Notice or about how we handle your health information should be submitted in writing. We will not retaliate against you in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services.

Send all written requests

Privacy Office
P.O. Box 30416
Lansing, MI 48909-7916