Authorization for Release of Protected Health Information
To be in compliance with the HIPAA Privacy Rule, a patient/guardian/personal representative must complete this form to authorize disclosure of confidential health information about any member/insured. Send the completed form to:

Privacy Office
PO Box 81889
Lincoln, NE 68510
Fax: 402-309-2580

English Authorization for Release of Protected Health Information
Spanish Authorization for Release of Protected Health Information

HIPAA Individual Rights Forms
Our HIPAA Privacy Notice describes member/insured’s rights with respect to the protected health information (PHI) we maintain. All requests in connection with these rights must be made in writing.

Request for Alternate Means of Communication
Request for Amendment of Protected Health Information
Request for Accounting of Disclosures of Protected Health Information
Request to Inspect or Copy Protected Health Information
Request to Restrict/Terminate Restrictions on Disclosures

Legal Information and Terms of Use

Product Issuers and Distributors
Ameritas Group, a division of Ameritas Life Insurance Corp. (Ameritas Life), a UNIFI company, offers group dental, vision and hearing care products nationwide. In New York, products are offered through Ameritas Life Insurance Corp. of New York (Ameritas of New York). Certain plan designs may not be available in all areas. In Texas, our PPO network and plans are referred to as the Ameritas Dental Network.

Legal Information and Terms of Use
This Legal Information and Terms of Use governs your access and use of the websites of the UNIFI Companies, their affiliates and subsidiaries. As used here "UNIFI Companies" refers to UNIFI Mutual Holding Company, Ameritas Life Insurance Corp., Ameritas Life Insurance Company of New York, Acacia Life Insurance Company, The Union Central Life Insurance Company, Ameritas Investment Corp., Summit Investment Advisors, Inc., Summit Investment Partners, Inc., Calvert, Ltd., Summit Mutual Funds, Inc., PRB Administrators, Inc., Acacia Federal Savings Bank, their affiliates and subsidiaries.

Your Acceptance of Terms
By linking, referencing, using or accessing websites of the UNIFI Companies, you agree to these Terms of Use, including agreeing to indemnify and hold harmless the UNIFI Companies from all claims of any nature. These Terms of Use may be changed at any time at the sole discretion of the UNIFI Companies.

Privacy
All personal information is subject to the Privacy Policy of the UNIFI Companies.

Products and Services
Products and services are offered through the UNIFI Companies. Not all products and services described are available in all states of the USA, or elsewhere in the world.

The product information contained on this website has been prepared for informational purposes only and is not intended to constitute a solicitation or offer for sale. For further information, please contact the UNIFI Companies affiliate offering the product, or your agent or representative through whom the product may be purchased, for detailed information about the product’s benefits, costs, risks and suitability for your specific needs.

Links to Other Websites - Limitation of Liability
The UNIFI Companies may provide, for your convenience and information only, links to other Internet websites. Because the UNIFI Companies do not have control over these sites, you agree that the UNIFI Companies are not responsible for any liability resulting from the access or use of sites not owned by the UNIFI Companies and that the UNIFI Companies are not responsible for any content, advertising, product, or any other matter or issue, available through other Internet websites, whether linked to, or from, websites of the UNIFI Companies. Further, you agree that the UNIFI Companies shall not be responsible or liable, directly or indirectly, for any damage or loss caused, or alleged to be caused by or in connection with the use of websites the UNIFI Companies own.

Indemnification
By linking, referencing, using or accessing web sites of the UNIFI Companies, you agree to these Terms of Use, including agreeing to defend, indemnify and hold harmless the UNIFI Companies, their officers, directors, employees, agents, licensors, suppliers and any other third party, without limitation, against all losses, expenses, damages and costs, including reasonable attorneys' fees, resulting from any violation of these "Terms of Use."

This Website - Disclaimer of Warranty and Limitation of Liability
USE OF THIS SITE IS ENTIRELY AT YOUR OWN RISK. THE SITE AND MATERIALS ARE PROVIDED "AS IS." TO THE MAXIMUM EXTENT PERMITTED BY LAW, THE UNIFI COMPANIES DISCLAIM ALL WARRANTIES OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING, WITHOUT LIMITATION, IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT, EVEN IF THE UNIFI COMPANIES HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGE. UNDER NO CIRCUMSTANCES SHALL THE UNIFI COMPANIES BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE OR EXEMPLARY DAMAGES ARISING FROM VIRUSES, WORMS, TROJAN HORSES OR OTHER CODE THAT HAS CONTAMINATING OR DESTRUCTIVE PROPERTIES OR YOUR REFERENCING, USING, ACCESSING, INABILITY TO USE OR ACCESS OR LINKING TO OR FROM THE WEBSITES OF THE UNIFI COMPANIES OR ANY ERRORS OR OMISSIONS IN THE CONTENT THEREOF. Some jurisdictions may not allow the exclusion of certain warranties or the limitation or exclusion of liability for consequential or incidental damages. If so, the liability of the UNIFI Companies is limited to the greatest extent permitted by law.

Governing Law: Severability
These Terms of Use are governed by the laws of the State of Nebraska without regard to that State’s principles of conflicts of laws. You consent to jurisdiction of the federal and state courts presiding in Lincoln, Nebraska, and agree to accept service of process by mail and hereby waive any and all jurisdictional and venue defenses otherwise available. This website is controlled and operated from the offices of the UNIFI Companies within the United States. The UNIFI Companies make no representation that the materials in this website are appropriate or available for use in other locations, and access to them from territories where their contents are illegal is prohibited.

In the event any of the provisions of these Terms of Use shall be determined by a court of competent jurisdiction to be invalid, any such provision determined to be invalid shall not effect the validity of all remaining provisions.

Copyright and Proprietary Rights in Marks, Logos and Materials
Copyright 2011, UNIFI Mutual Holding Company. Materials and intellectual property found on websites of The UNIFI Companies are protected by copyright and other intellectual property laws and treaties in the United States and worldwide. Trademarks, service marks and logos used on websites of The UNIFI Companies are registered and unregistered trademarks, subject to the laws of the United States and other countries worldwide. Trademarks, service marks and logos used on these websites that have been provided by others are the property of their respective owners. You may not copy, modify, store, transmit, reproduce or distribute any part of the information or content of or trademarks, service marks or logos used on these websites without the specific written consent of The UNIFI Companies or their respective owners. If you would like to link to any website of The UNIFI Companies or use its logos on your site, please contact us.

Proprietary Marks and Logos
The entire content of this website, including all text, graphics, images, photos, video, audio, logos, other material and the arrangement of such content, is owned by UNIFI Companies or their affiliates and subsidiaries and is protected by copyright under United States and foreign laws, unless otherwise indicated. Ameritas and the bison symbol is a service mark or registered service mark of Ameritas Life Insurance Corp. Ameritas Life Insurance Corp. of New York is a registered service mark of Ameritas Life Insurance Corp. of New York. Other products and services described on this website are the marks of the UNIFI Companies unless otherwise indicated.

How to Contact Us
Address inquiries concerning the use of any copyrighted material, trademarks, service marks or other intellectual property to Ameritas Life Insurance Corp., Group Communications, 5900 O Street, Lincoln, NE 68510 USA.

UNIFI Companies Privacy and Legal Information
Privacy Policy
Legal Policy

Insurance Companies Licensing Information

Ameritas Life Insurance Corp.
NAIC #943-61301
Licensed in all States except New York

Ameritas Life Insurance Corp. of New York
NAIC #943-60033
Licensed in the State of New York

Acacia Life Insurance Company
NAIC #437-60038
Licensed in all States except Alaska, Maine, and New York

The Union Central Life Insurance Company
NAIC #394-80837
Licensed in all States