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DentDisc-Contract.001 (TX) 04.18.08 Texas Dental Plans, Inc. A Discount Health Care Card Program Operator Registered Under Chapter 76, Texas Health and Safety Code Dental Discount Plan Contract In consideration of the Application made by the Contractholder, and in consideration of payment by the Contractholder of the appropriate fees and charges, Texas Dental Plans, Inc. (hereinafter called “Plan”) shall provide access for Plan members to receive dental services from Plan dentists at a discount. Agreement This Contract is the entire agreement between the Contractholder and the Plan. This Contract shall be effective for an initial term of twelve months from the effective date and continuing thereafter for periods of 12 months each until terminated by either party with prior written notice or as otherwise specified in the Contract. Only authorized officers may make changes for the Plan. Such changes must be in writing and attached to this Contract. The Plan reserves the right to amend the Contract from time to time. This Contract is governed by the laws of the State of Texas. Incorporation Provision The provisions of this Contract, Application, Schedule of Benefits, and all rider(s) issued to amend this Contract on or after the effective date are made a part of this Contract. This Contract was signed by the Contractholder on the Application form. We sign here on behalf of Texas Dental Plans, Inc. __________________ Gerald L. Ganoni President This discount health care card program is NOT insurance. The Plan provides discounts at certain health care providers for dental services. The Plan does not make payments directly to the providers of dental services. The Plan member is obligated to pay for all dental care services but will receive a discount from those health care providers who have contracted with the Plan. The Plan’s administrative office address is P.O. Box 769729, Roswell, GA 30076. For member assistance and plan information, please call the Customer Care Department at (800) 488-2801. Right of Cancellation. If the Member cancels the membership within the first 30 days after receipt of the discount card and other membership materials, the Member shall receive a reimbursement of all periodic charges paid other than money paid as a nominal one-time enrollment fee or money paid by the Member to a Participating Dentist for services or products received. The return of all periodic charges shall be made within 30 days of the date of cancellation.

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Page 1: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

DentDisc-Contract.001 (TX)04.18.08

- 1 -

Texas Dental Plans, Inc.A Discount Health Care Card Program Operator

Registered Under Chapter 76, Texas Health and Safety Code

Dental Discount PlanContract

In consideration of the Application made by the Contractholder, and in consideration of payment by theContractholder of the appropriate fees and charges, Texas Dental Plans, Inc. (hereinafter called “Plan”) shall provideaccess for Plan members to receive dental services from Plan dentists at a discount.

Agreement

This Contract is the entire agreement between the Contractholder and the Plan. This Contract shall be effective foran initial term of twelve months from the effective date and continuing thereafter for periods of 12 months each untilterminated by either party with prior written notice or as otherwise specified in the Contract. Only authorizedofficers may make changes for the Plan. Such changes must be in writing and attached to this Contract. The Planreserves the right to amend the Contract from time to time. This Contract is governed by the laws of the State ofTexas.

Incorporation Provision

The provisions of this Contract, Application, Schedule of Benefits, and all rider(s) issued to amend this Contract onor after the effective date are made a part of this Contract. This Contract was signed by the Contractholder on theApplication form. We sign here on behalf of Texas Dental Plans, Inc.

__________________

Gerald L. GanoniPresident

This discount health care card program is NOT insurance. The Plan provides discounts at certain health care providersfor dental services. The Plan does not make payments directly to the providers of dental services. The Plan member isobligated to pay for all dental care services but will receive a discount from those health care providers who havecontracted with the Plan. The Plan’s administrative office address is P.O. Box 769729, Roswell, GA 30076. For memberassistance and plan information, please call the Customer Care Department at (800) 488-2801.

Right of Cancellation. If the Member cancels the membership within the first 30 days after receipt of the discount cardand other membership materials, the Member shall receive a reimbursement of all periodic charges paid other than moneypaid as a nominal one-time enrollment fee or money paid by the Member to a Participating Dentist for services or productsreceived. The return of all periodic charges shall be made within 30 days of the date of cancellation.

Page 2: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

DentDisc-Contract.001 (TX)- 2 -

DEFINITIONS

Contractholder – means the individual, association, employer, trust or organization to which this Contract for DentalDiscount Plan has been issued.

Member- means the Subscriber and covered household members of a Subscriber.

Plan, We, Us or Our- means Texas Dental Plans, Inc.

Schedule of Benefits – means the listing of the discounted fees off the Participating General Dentist or ParticipatingSpecialist Dentists usual fees.

Subscriber- in the case of an individual plan, Subscriber means the Contractholder. For group plans, Subscriber means anindividual of the group in good standing for whom the necessary fees and charges have been paid to the Plan.

Participating Dentist – means a Participating General Dentist or Participating Specialist Dentist.

Participating General Dentist - a licensed general dentist under agreement with the Plan to provide discounted dentalservices to Plan Members.

a licensed specialty dentist under agreement with the Plan to provide discounted dentalservices to Plan Members.

DENTAL DISCOUNT BENEFITS

When the Member receives dental services from a Participating Dentist the Member is entitled to a discount off theParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate aParticipating Dentist by using the provider locator on Our website at www.humanaonedental.com or by contacting OurCustomer Care Department at (800) 488-2801. The Member simply makes an appointment with a Participating Dentist andpresents his/her identification card at the time of the appointment in order to receive the applicable discount. If the Memberdoes not identify him/herself as a Plan Member and present his/her identification card at the time of service, theParticipating Dentist is not obligated to honor the discounted rate and may elect to charge the Member his usual and normalfee. The Member is responsible to make payment for dental services directly to the Participating Dentist at the time servicesare rendered. The Plan does not guarantee the quality of the services or products offered by Participating Dentists.

ADDING NEW HOUSEHOLD MEMBERS

Any individual residing in your household may be added at any time by contacting the Plan and paying the additionalcharges and fees, if applicable. The newly added individual’s access to discount dental services will become effective onthe date indicated by the Plan.

RENEWAL, TERMINATION AND CANCELLATION

This contract will renew automatically on its anniversary date for twelve month periods if all appropriate charges and feeshave been paid. This Contract may be terminated by either party at any time during the membership period. The Plan willcease collecting charges and fees within 30 days of receipt of a written cancellation notice. This Contract will terminateimmediately and without notice for failure to pay all appropriate charges and fees.

LIMITATIONS AND EXCLUSIONS

1. Services for injuries or conditions that are covered under Workman’s Compensation or Employer’s Liability laws.

2. Services that are provided without cost to the Member by any municipality, county or other political subdivision.

3. Cost of dental care, which is covered under automobile, medical, no fault or similar type insurance.

4. General anesthesia (put to sleep), I.V. sedation, Nitrous Oxide and hospitalization or hospital or medical charges of anykind.

Participating Specialist Dentist -

Page 3: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

DentDisc-Contract.001 (TX)- 3 -

5. Osseointegrated implants.

6. Member’s dental fees apply only when treatment is performed at a Participating Dental office. If the services of a non-participating specialist or non-participating general dentist are required, those dental fees do not apply and the Memberwill be responsible to the non-participating dentist for his usual, customary and reasonable fee.

7. Reduced fees will not be honored if dental treatment is already in progress or if the Member’s membership is no longervalid.

8. Any member accepted for orthodontic treatment must remain a member of the dental plan for the full duration of theirtreatment or risk additional charges from their participating Orthodontist.

9. A Member’s existing dental or medical condition may necessitate extra precautionary procedures and requireadditional charges. Please discuss all fees with the dentist prior to treatment.

MEMBER COMPLAINTS

Any Member who wishes to register a complaint may submit a grievance to the Plan in writing or by calling Our CustomerCare Department at (800) 488-2801. A written grievance must be identified as such and submitted to the Plan’s GrievanceCoordinator within one year from the date of the occurrence of the events upon the grievance is based. The writtengrievance must contain the Member's name, address, phone number, ID number, signature, date, and the action requested.Assistance with the Plan's grievance procedures may be obtained by contacting the Customer Care Department at (800)488-2801. Written grievances should be mailed to:

Grievance CoordinatorTexas Dental Plans, Inc.

5775 Blue Lagoon Drive, Suite 400Miami, FL 33126-2034

All grievances will be acknowledged in writing within 5 business days after receipt. Complaints will be researched andresolved within 30 days from the date of receipt.

GENERAL PROVISIONS

Contract Changes- The Plan may change the amounts shown in the Schedule of Benefits or delete, amend, or limit anyterms under the Contract upon not less than 30 days prior written notice to the Contractholder. It is the responsibility of theContractholder to notify all Members of any such changes to the Contract.

Conformity with Texas Law- This Contract shall be interpreted in accordance with the laws of the State of Texas and anyaction or claim shall be brought within the State of Texas. Any statute, act, ordinance, rule or regulation of anygovernmental authority with jurisdiction over Texas Dental Plans, Inc. shall have the effect of amending this Contract toconform with the minimum requirements thereof. In the event any portion of this Contract is held to be void, it shall notaffect any other provisions.

Notice of Independent Contractor Relationship – The Plan assumes responsibility of fulfilling the terms of this Contract.Participating Dentists are independent contractors, and the Plan cannot be held responsible for any damages incurred as aresult of tort, negligence, breach of contract, or malpractice by Participating Dentists for any damage which result from anydefective or dangerous condition in or about any facility which services are rendered or materials are provided hereunder.

Worker’s Compensation Act – The coverage under the Contract is not in lieu of and does not affect any requirement forcoverage by any Worker’s Compensation Act, or other similar legislation.

Note to Texas Consumers- Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin,Texas 78711; telephone (800) 803-9202 or (512) 463-6599; website: www.license.state.tx.us/complaints.

Notices - All notices, changes, or requests by Contractholder shall be made in writing and shall be furnished by UnitedStates Mail to Texas Dental Plans, Inc. at the administrative office address listed on the face page of this Contract.

Page 4: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

Diagnostic and Preventive DentistryD0120 Periodic oral evaluation.............................................................................................15D0150 Comprehensive oral evaluation ...............................................................................15D0210 Intraoral - complete series (including bitewings) .....................................................30D0220 Intraoral - periapical - first film....................................................................................5D0230 Intraoral - periapical each additional film...................................................................4D0270 Bitewing - single film...................................................................................................5D0330 Panoramic film ......................................................................................................... 30D0460 Pulp vitality tests ...................................................................................................... 12D0470 Diagnostic casts....................................................................................................... 20D1110 Prophylaxis - adult ................................................................................................... 29D1120 Prophylaxis - child.................................................................................................... 29D1351 Sealant - per tooth.................................................................................20% Discount(Patients who have not had regular cleanings may require gum treatment)D4355 Full mouth debridement to enable comprehensive periodontal evaluation and

diagnosis....................................................................................................................45D9310 Consultation (diagnostic service provided by dentist or physician other

than practitioner providing treatment)......................................................15/10-OrthoD9999 Infection control fee ................................................................................................... 9**Infection control guidelines have been established by OSHA and the American Dental Association.

Infection control measures will be charged routinely by a participating dental office.

Cosmetic and Restorative DentistryPermanent and “Baby” TeethAmalgam Restorations (Silver Fillings)D2110 Amalgam - one surface, primary..............................................................................34D2120 Amalgam - two surfaces, primary ............................................................................44D2130 Amalgam - three surfaces, primary..........................................................................54D2140 Amalgam - one surface, permanent ........................................................................34D2150 Amalgam - two surfaces, permanent.......................................................................44D2160 Amalgam - three surfaces, permanent ....................................................................54Resin Fillings (Tooth Colored)D2330 Resin - based composite - one surface, anterior....................................................34D2331 Resin - based composite - two surfaces, anterior ..................................................44D2332 Resin - based composite - three surfaces, anterior................................................54D2380 Resin - based composite - one surface, posterior primary.................20% DiscountD2381 Resin - based composite - two surfaces, posterior primary...............20% DiscountD2382 Resin - based composite - three surfaces, posterior primary.............20% DiscountD2385 Resin - based composite - one surface, posterior permanent ...........20% DiscountD2386 Resin - based composite - two surfaces, posterior permanent .........20% DiscountD2387 Resin - based composite - three surfaces, posterior permanent .......20% DiscountD2388 Resin - based composite - four/more surfaces,

posterior permanent ..............................................................................20% DiscountD2951 Pin retention - per tooth, in addition to restoration .................................................16Crown and BridgeD2751 Crown - porcelain fused to predominantly base metal*.............................321 + LabD2791 Crown - full cast predominantly base metal*..............................................300 + LabD2810 Crown - 3/4 cast predominantly base metal* .............................................300 + LabD2950 Core buildup, including any pins ..........................................................20% DiscountD6211 Pontic - cast predominantly base metal* ....................................................300 + LabD6241 Pontic - porcelain fused to predominately base metal* .............................321 + LabD6751 Crown - porcelain fused to predominately base metal* .............................321 + LabD6791 Crown - full cast predominantly base metal*..............................................300 + Lab*Lab charges additional - no discount.

Endodontic Dentistry (Root Canal Treatment)D3110 Pulp cap-direct (excluding final restoration) ............................................................19D3120 Pulp cap-indirect (excluding final restoration)..........................................................19D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal

to the dentinocemental junction and application of medicament ......................... 43Root CanalsD3310 Root canal therapy - anterior (excluding final restoration) ....................................199D3320 Root canal therapy - bicuspid (excluding final restoration)...................................236D3330 Root canal therapy - molar (excluding final restoration) .......................................279Any Root Canal treatment or retreatment that presents unusual difficulties and circumstances mayhave an additional charge. Please discuss all fees with the general dentist prior to treatment.

Oral SurgeryD7110 Extraction, single tooth ............................................................................................ 35D7210 Surgical removal of erupted tooth requiring elevation of mucoperiostial

flap and removal of bone and/or section of tooth...................................................65D7220 Removal of impacted tooth - soft tissue .................................................................99D7230 Removal of impacted tooth - partially bony ..........................................................120D7240 Removal of impacted tooth - completely bony.....................................................142D7510 Incision and drainage of abscess - intraoral soft tissue..........................................32Any tooth that presents unusual difficulties and circumstances may incur an additional charge.Please discuss all fees with the dentist prior to treatment.

Prosthodontic Dentistry (Dentures)*D5110 Complete denture - maxillary* .....................................................................414 + LabD5120 Complete denture - mandibular* .................................................................414 + LabD5211 Maxillary partial denture - resin base (including any conventional

clasps, rests and teeth)*...............................................................................403 + LabD5212 Mandibular partial denture - resin base (including any conventional

clasps, rests and teeth)* ..............................................................................403 + LabD5213 Maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)* .....................403 + LabD5214 Mandibular partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)*......................403 + LabProsthetics (dentures) fees are our reduced fees for usual and customary services. Any prostheticappliance that requires unusual services may be an additional charge. Discuss all fees with thegeneral dentist prior to any treatment.*Lab charges additional - no discount.

Orthodontic Dentistry (Braces by a General Dentist)D8660 Pre-orthodontic treatment visit...............................................................................120D9310 Consultation (diagnostic service provided by dentist or physician other

than practitioner providing treatment) ........................................................5/10-OrthoOrthodontic Treatment (braces)D8080 Comprehensive orthodontic treatment of the adolescent dentition..................2,150D8090 Comprehensive orthodontic treatment of the adult dentition............................2,350See 4. Plan Exclusions and LimitationsThe above orthodontic charges are our reduced fees for full banded Class I malocclusion cases. Anyorthodontic treatment that requires surgery, headgear, unusual or ancillary services or is extendedbecause of lack of patient cooperation will have an additional charge. At the orthodontic consultationappointment, the general dentist will explain the length of treatment, all fees, and the paymentschedule. Orthodontic services are offered on a space and time available basis only and are notavailable to any person that is currently in treatment or has had treatment planned by any dentist inthe past 6 months.Broken or lost appliances will be an additional charge.

Periodontic Dentistry (Gum Disease Treatment)D4250 Mucogingival surgery - per quadrant.....................................................................350D4260 Osseous surgery (including flap entry and closure) - per quadrant .....................480D4341 Periodontal scaling and root planing - per quadrant ..............................................65D4910 Periodontal maintenance procedures (following active therapy) ............................48At the diagnostic evaluation appointment, the participating general dentist will explain thetreatment procedure and the fees. The above periodontic charges are our reduced fees for usualand customary periodontal services. Any periodontal treatment that requires root resection, gingivalgrafts, or other services will have an additional charge at a reduced rate. Discuss this with the dentistprior to beginning treatment.

GeneralD9110 Palliative (emergency) treatment of dental pain ...................................20% DiscountD9430 Office visit for observation (during regularly scheduled hours)...............................12D9440 Office visit - after regularly scheduled hours .......................................................UCRD9999 Broken Appointment within 24 hours.......................................................................25

Member’s Services Member Pays Member’s Services Member Pays

All of the listed charges are reduced fees for services performed by a participating generaldentist. Fees are subject to change without notice.

Specialty DentistryAny treatment provided by a participating specialist, if available, in Endodontics (root canal),Pediatric Dentistry (children’s dentistry), Prosthodontics (Dentures), Orthodontics (teethstraightening), Periodontics (gum disease treatment) or Oral Surgery will be charged at a 20%reduction of participating specialist’s fees for that particular case. Some specialists may require aconsultation visit before treatment is initiated. Discuss each case with the specialist prior tobeginning any treatment.

Any procedure not listed is available on a fee for service basis at a 20% discount.Consult with your participating general dentist prior to beginning any treatment.

Plan Exclusions and Limitations1. The following exclusions apply:

A. Services for injuries or conditions that are covered under Workman’s Compensation orEmployer’s Liability Laws;

B. Services, which are provided without cost to the member by any municipality, county orother political subdivision;

C. Cost of dental care, which is covered under automobile, medical, no fault, or similar typeinsurance;

D. General anesthesia (put to sleep), I.V. sedation, Nitrous Oxide, and hospitalization orhospital or medical charges of any kind; and

E. Osseointegrated implants.2. Member’s dental fees apply only when treatment is performed at a PARTICIPATING DENTAL

OFFICE. If the services of a non-participating specialist or non-participating general dentist arerequired, these dental fees do not apply and the patient will be responsible to the non-participating dentist for his usual, customary and reasonable fee.

3. Reduced fees will not be honored if dental treatment is already in progress or if the patient’smembership is no longer valid.

4. Any member accepted for orthodontic treatment must remain a member of the dental plan forthe full duration of their treatment or risk additional charges from their participatingOrthodontist.

5. A patient's existing dental or medical condition may necessitate extra precautionaryprocedures and require additional charges. Please discuss all fees with the dentist prior totreatment.

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

Dental Disount Plan Texas Dental PlansMember Dental Fees

Texas

Page 5: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATIONABOUT YOU MAY BE USED AND DISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION. PLEASEREVIEW IT CAREFULLY.

Under the Health Insurance Portability and Accountability Act of1996 (“HIPAA”) we are required to maintain the privacy of your pro-tected health information and provide you with notice of our legalduties and privacy practices with respect to such protected healthinformation.

We are required to abide by the terms of the notice currently ineffect. We reserve the right to change the terms of our notice atany time and to make the new notice provisions effective for allprotected health information that we maintain. In the event that wemake a material revision to the terms of our notice, you will receivea revised notice within 60-days of such revision. If you shouldhave any questions or require further information, please contactour Privacy Officer at (770) 998-8936 or toll free at (800) 342-5209.

How We May Use or Disclose Your Health Information

The following describes the purposes for which we are permittedor required by law to use or disclose your health information with-out your consent or authorization. Any other uses or disclosureswill be made only with your written authorization and you mayrevoke such authorization in writing at any time.

Treatment: We may use or disclose your health information toprovide you with medical treatment or services. For example,information obtained by a provider providing health care servicesto you will record such information in your record that is related toyour treatment. This information is necessary to determine whattreatment you should receive. Health care providers will alsorecord actions taken by them in the course of your treatment andnote how you respond.

Payment: We may use or disclose your health information in orderto process claims or make payment for covered services youreceive under your benefit plan. For example, your provider maysubmit a claim to us for payment. The claim form will include infor-mation that identifies you, your diagnosis, and treatment or sup-plies used in the course of treatment.

Health Care Operations: We may use or disclose your healthinformation for health care operations. Health care operationsinclude, but not limited to, quality assessment and improvementactivities, underwriting, premium rating, management and generaladministrative activities. For example, members of our qualityimprovement team may use information in your health record toassess the quality of care that you receive and determine how tocontinually improve the quality and effectiveness of the serviceswe provide.

Business Associates: There may be instances where servicesare provided to our organization through contracts with third-party“business associates”. Whenever a business associate arrange-ment involves the use or disclosure of your health information, wewill have a written contract that requires the business associate tomaintain the same high standards of safeguarding your privacythat we require of our own employees and affiliates.

Required by Law: We will disclose medical information aboutyou when required to do so by federal, state or local law.

Communication with Family or Friends: Our service profession-als, using their best judgement, may disclose to a family member,other relative, close personal friend, or any other person you iden-tify, health information relevant to that person’s involvement in yourcare or payment related to your care.

Marketing: We may use or disclose your health information, asnecessary, to provide you with information about treatment alter-natives or other health-related benefits and services that may be ofinterest to you.

Research: We may disclose information to researchers whentheir research has been approved by an institutional review boardthat has reviewed the research proposal and established protocolsto ensure the privacy of your health information.

Coroners, Medical Examiners and Funeral Directors: We maydisclose health information to a coroner or medical examiner. Wemay also disclose medical information to funeral directors consis-tent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicablelaw, we may disclose health information to organ procurementorganizations or other entities engaged in the procurement, bank-ing, or transplantation of organs for the purpose of tissue donationand transplant.

Fund Raising: We may contact you as part of a fund-raisingeffort.

Public Health: As required by law, we may disclose your healthinformation to public health or legal authorities charged with pre-venting or controlling disease, injury or disability.

Food and Drug Administration (FDA): We may disclose to theFDA health information relative to adverse events with respect tofood, supplements, product and product defects, or post marketingsurveillance information to enable product recalls, repairs, orreplacement.

NOTICE OF PRIVACY PRACTICESEffective April 14, 2003

Page 6: Texas Dental Plans, Inc. Fee Schedule.pdfParticipating Dentist’s usual charge for dental services, as shown in the Schedule of Benefits. The Member may locate a Participating Dentist

Workers’ Compensation: We may disclose health information tothe extent authorized by and to the extent necessary to complywith laws relating to workers compensation or other similar pro-grams established by law.

To Avert a Serious Threat to Health or Safety: Consistent withapplicable federal and state laws, we may use and disclose healthinformation when necessary to prevent a serious threat to yourhealth and safety or the health and safety of the public or anotherperson.

Military and Veterans: If you are a member of the armed forces,we may disclose health information about you as required by mili-tary command.

Health Oversight Activities: We may disclose health informationto a health oversight agency for activities authorized by law, includ-ing audits, investigations, inspections, and licensure.

Protective Services for the President, National Security andIntelligence Activities: We may disclose health information aboutyou to authorized federal officials so they may provide protection tothe President, other authorized persons or foreign heads of stateor conduct special investigations, or for intelligence, counterintelli-gence, and other national security activities authorized by law.

Law Enforcement: We may disclose health information whenrequested by a law enforcement official as part of law enforcementactivities; investigations of criminal conduct; in response to courtorders; in emergency circumstances; or when required to do so bylaw.

Inmates: We may disclose health information about an inmate ofa correctional institution or under the custody of a law enforcementofficial to the correctional institution or law enforcement official.

Lawsuits and Disputes: We may disclose health informationabout you in response to a subpoena, discovery request, or otherlawful order from a court.

Plan Sponsors: We may disclose health information about you toyour plan sponsor to carry out plan administration functions thatthe plan sponsor performs upon certification by the plan sponsorthat the plan documents have been amended as set forth underHIPAA regulations.

Your Rights Regarding Your Health Information

The following describes your rights regarding the health informa-tion we maintain about you. To exercise your rights, you mustsubmit your request in writing to our Privacy Officer at 100 MansellCourt E., Suite 400, Roswell, GA 30076.

Right to Request Restrictions. You have the right to requestthat we restrict uses or disclosures of your health information tocarry out treatment, payment, health care operations, or communi-cations with family or friends. We are not required to agree to arestriction.

Right to Receive Confidential Communications. You have theright to request that we send communications that contain yourhealth information by alternative means or to alternative locations.We must accommodate your request if it is reasonable and youclearly state that the disclosure of all or part of that informationcould endanger you.

Right to Inspect and Copy. You have the right to inspect andcopy health information that we maintain about you in a designat-ed record set. A “designated record set” is a group of records thatwe maintain such as enrollment, payment, and claims adjudicationrecord systems. If copies are requested or you agree to a summa-ry or explanation of such information, we may charge a reason-able, cost-based fee for the costs of copying, including labor andsupply cost of copying; postage; and preparation cost of an expla-nation or summary, if such is requested. We may deny yourrequest to inspect and copy in certain circumstances as defined bylaw. If you are denied access to your health information, you mayrequest that the denial be reviewed.

Right to Amend. You have the right to have us amend yourhealth information for as long as we maintain such information.Your written request must include the reason or reasons that sup-port your request. We may deny your request for an amendmentif we determine that the record that is the subject of the requestwas not created by us, is not available for inspection as specifiedby law, or is accurate and complete.

Right to Receive an Accounting of Disclosures. You have theright to receive an accounting of disclosures of your health infor-mation made by us in the six years prior to the date the account-ing is requested (or shorter period as requested). This does notinclude disclosures made to carry out treatment, payment andhealth care operations; disclosures made to you; communicationswith family and friends; for national security or intelligence purpos-es; to correctional institutions or law enforcement officials; or dis-closures made prior to the HIPAA compliance date of April 14,2003. Your first request for accounting in any 12-month periodshall be provided without charge. A reasonable, cost-based feeshall be imposed for each subsequent request for accounting with-in the same 12-month period.

Right to Obtain a Paper Copy. You have the right to obtain apaper copy of this Notice of Privacy Practices at any time.

How to File a Complaint if You Believe Your Privacy RightsHave Been Violated

If you believe that your privacy rights have been violated, pleasesubmit your complaint in writing to:

CompBenefitsAttn: Privacy Officer

100 Mansell Court East, Suite 400Roswell, GA 30076

You may also file a complaint with the Secretary of the Departmentof Health and Human Services. You will not be retaliated againstfor filing a complaint.

The Humana Family of Companies

This notice is provided to you by the Humana family of companies:CompBenefits Insurance Company, American DentalProviders of Arkansas, Inc., CompDent of Alabama, Inc., OHS ofAlabama, Inc., American Dental Plan, Inc., Oral Health Services,Inc., Vision Care, Inc., CompDent of Illinois, Inc., CompDent Corp.,American Dental Plan of North Carolina, Inc., DentiCare, Inc (d/b/aCompDent), Texas Dental Plans, Inc. The Humana family ofcompanies are affiliated companies and may share health information with each other as necessary to carry out treatment,payment, or health care operations.