10 Copayment Preventive Plan - Dominion Dental Services, Inc.

How we protect your rights to privacy and confidentiality
We know that protecting your privacy rights is important. Therefore, we believe you should know how
we keep your personal and medical information confidential and how we may use it. A more complete
description of our privacy practices may be found in our notice of privacy practices. New subscribers
receive a copy of this notice by mail at the time of enrollment. You may also obtain a copy by
calling Member Services or at any Kaiser Permanente medical center.
We have many guidelines in place to protect your rights to privacy and confidentiality. Here are a few
examples:
1. Our physicians and employees sign confidentiality statements. This affirms their commitment to
protect your information. Only those who “need to know” to make decisions about your health
care are permitted to view your medical record.
2. Our physicians, employees, and other workforce members receive training on the state and
federal standards for the use and disclosure of your protected health information.
3. Contractors also sign a statement that they will protect your information.
4. Your right to have confidential medical records is part of our members’ rights and responsibilities.
5. You have the right to deny release of your information. This is so except when: required by
law; permitted for your treatment; permitted for payment of services; or allowed for health plan
operations.
6. Except as permitted by law, we take out any information that could identify you before talking to
your employer or employer representative about the use or cost of services.
7. Our staff will ask to see a valid photo ID when you request care or services. If you don’t have a
valid ID, we will ask you one or two questions that will help us confirm your identity.
Except as permitted by law, we must have your permission in writing before we can share your information
for the reasons that follow. The release must explain the exact information to be shared and be
signed by you. Your member services representative can give you more details and a release form.
1. Giving your employer or employer representative the status of your claims.
2. Sharing your medical information with an outside party, except when required or permitted
for legal or regulatory reasons or as allowed for treatment, payment, or health plan operation
purposes.
We may use your protected information in the following day-to-day operations of the health plan.
These tasks are in agreement with the Health Insurance Portability and Accountability Act (HIPAA)
and the general release of information in your agreement or Evidence of Coverage.
1. Talking with your employer representative about changes to your membership information.
2. Giving a parent the status of his or her child’s claim (if the child is under 18 years of age and there
is no legal reason not to do so).
3. Providing your name and address to our contracted mail houses. This is so you can receive our
health mailings to prevent or manage chronic diseases, and other health care information.
4. Sharing information with government agencies or other insurers for liability or payment purposes.
5. Providing information as required or permitted by federal, state, or local laws.
6. Supporting medical research, as permitted by law.
7. Professional, tracking, or quality improvement tasks.
Note: “You” may also refer to your authorized representative.
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