Fill and Sign the Form 593

MUTUAL OF OMAHA PRIVACY NOTICE—MEDICAL INFORMATION ATTACHMENT FOR RESIDENTS OF NEW HAMPSHIRE HIV/AIDS-Related Tests: We will not test an individual for HIV in connection with an application for insurance or any increased or additional benefits unless the individual provides written consent using the standard form approved by New Hampshire law. We will only use and disclose the results of HIV/AIDS-related tests as permitted by law. All information in our possession regarding the results of any test for HIV will be maintained as confidential information and will be protected against inadvertent or unwarranted intrusion. Our policies and procedures are designed to assure that only those officers, employees, or agents whose official duties establish a need for information regarding test results will have access to such information. Test result information obtained by subpoena or any other method of discovery will not be disclosed outside of the proceedings for which the information was obtained. Appeal of Claim Denial: When appealing a denial of a claim, the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claimant’s claim for benefits. Managed Care Plan: Data or information pertaining to the diagnosis, treatment, or health of a covered person is confidential and will not be disclosed unless permitted by law. MC20368_NH A health carrier is entitled to claim any statutory privileges against disclosure that the provider who furnished the information to the health carrier is entitled to claim. The records of a quality assessment program, and the information considered by any quality committee and the records of its actions and proceedings will be confidential and not subject to subpoena or order to produce except as permitted by law. Policy Numbers: We will not disclose policy numbers to a nonaffiliated third party for use in telemarketing, direct mail marketing, or other marketing through electronic mail, unless permitted by New Hampshire law. Authorizations: If an individual provides us with an authorization to disclose medical information, the authorization will include the identity of the individual, and it will only be valid for 24 months. An authorization may be revoked at any time subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation.