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About LIBERTY Dental Plan






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.” This 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 needed, to carry out payment or health care operations relating to the services to be provided at the Plan facilities.

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. 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 from the Privacy Officer at the Plan. You can also access it on our website at:


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 use or disclosure will be listed.

  • Treatment means the provision, coordination or management of your health care. This includes 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 manage your care.
  • Payment means the activities we undertake to reimburse providers for the health care provided to you. This includes 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 needed to obtain payment.
  • 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. Others can use the de-identified information to study health care and health care delivery without learning who you are.


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 person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or help in the report 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.
  • 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.
  • We may use your information for underwriting purposes.
  • We will not disclose genetic information for this purpose.
  • We may contact you as part of our advertising efforts as allowed by applicable law.
  • We will use or disclose PHI about you when needed 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 allowed uses or disclosures which are limited in nature and cannot be reasonably prevented.


Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:

  • 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.
  • 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;
    • 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; or
    • 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.
  • Health Oversight Activities. We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing healthcare, seeking payment, and civil rights).
  • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may release PHI subject to certain limitations.
  • Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
    • 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 circumstances;
    • About a death we believe may be the result of criminal conduct;
    • About criminal conduct on our properties; or
    • In emergency circumstances, to report a crime, the location of the crime or the vi ctims, or the identity, description or location of the person who committed the crime.
  • 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 needed to carry out their duties.
  • 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.
  • 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. Also, if it is needed for law enforcement authorities to identify or apprehend an individual.

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.


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. By providing that the revocation is in writing, except to the extent that we already have acted in support on your authorization.


  1. 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.
  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.
  3. You have the right to inspect and copy the PHI contained in our Plan records, except:
    1. for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
    2. 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;
    3. for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
    4. 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 information.

      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, or other costs associated with your request.

      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
  4. You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:
    1. 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;
    2. is not part of your medical or billing records or other records used to make decisions about you;
    3. is not available for inspection as set forth above; or
    4. 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. 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.
  5. 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.
  6. You have the right to receive a notice, if there is a breach of your unsecured PHI, which requires a notice under the Privacy Rule.


If you believe that your privacy rights have been violated, you should immediately contact the Privacy Officer at

Phone: 888-704-9833
Fax: 888-273-2718

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 became effective on November 1, 2016 and was last reviewed and approved on October 14, 2020.

Organizations Covered by Joint Notice

This Joint Notice describes the privacy practices of LIBERTY Dental Plan Corporation, its affiliated entities, divisions, pro grams, departments and units, including, but not limited to:
LIBERTY Dental Plan Corporation, a Nevada Corporation
LIBERTY Dental Plan of California, Inc., a California Corporation
LIBERTY Benefits Administrators, Inc., a California Corporation
LIBERTY Dental Plan of Nevada, Inc., a Nevada Corporation
LIBERTY Dental Plan of the Southeast, Inc., a Nevada Corporation
LIBERTY Dental Plan of Texas, Inc., a Nevada Corporation
LIBERTY Dental, P.A., a Texas Professional Association
LIBERTY Dental Plan of Florida, Inc., a Florida Corporation
LIBERTY Dental New York, Inc., a New York Corporation
LIBERTY Dental and Vision, Inc., a Nevada Corporation
LIBERTY Dental Plan of Missouri, Inc., a Missouri Corporation
LIBERTY Dental Plan Reinsurance Company, Ltd.
LIBERTY Dental Plan of New Jersey, Inc., a New Jersey Corporation
LIBERTY Dental Plan East, LLC, a New Jersey Limited Liability Company
LIBERTY Dental New York, LLC (LIBERTY Dental New York IPA, LLC in NJ and NY)